Healthcare Systems and Population Health PDF

Healthcare Systems and Population Health I. INTRODUCTION A. Review Aspects of Healthcare Systems and Population Health B. Describe Evidence-Based Practices for Teaching and Patient Education II. QUALITY IMPROVEMENT (QI) A. Quality Assurance (inspection of processes) 1. Punishing individ...

Healthcare Systems and Population Health I. INTRODUCTION A. Review Aspects of Healthcare Systems and Population Health B. Describe Evidence-Based Practices for Teaching and Patient Education II. QUALITY IMPROVEMENT (QI) A. Quality Assurance (inspection of processes) 1. Punishing individuals for errors 2. Myth that perfection was required of health care providers (and was attainable) 3. Quality control, as in manufacturing B. Paradigm Shift in QI 1. Publications by the Institute of Medicine (now the National Science Academy) a.  “To Err Is Human: Building a Safer Health System” and “Crossing the Quality Chasm: A New Health System for the 21st Century” b. Themes to improve quality i. Human factors engineering ii. Health information infrastructure iii. Meaningful use of health information technology iv. Improved access to information v. Protection of health information c. Call for change in health care delivery to improve health care outcomes by revision of patient care processes and the patient–provider relationship C. Principles of QI 1. Focus on the system and the team as large contributors to medical errors 2. Recognize the fallibility of humans in providing patient care 3. Evaluate errors as an opportunity to learn ways to improve the system 4. System should have checks and balances that support the individual so that errors are unlikely. 5. Errors are reviewed by peers to identify contributors to their occurrence so that changes can be adopted to prevent a future error. D. W. Edwards Deming 1. Champion for QI 2. 14 points written for manufacturing QI that provide a foundation for looking at controlling the variability in processes in order to achieve improvement (Box 1) 3. Provide guidance for health care organization QI E. Application to Healthcare 1. W hen first proposed, many individuals doubted they could be applied in the healthcare industry. a. Variability of the human condition b. Unique individual issues 2. Have proven useful in reducing variability and involving the workforce in improvement of processes ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-7 Healthcare Systems and Population Health F. When an Organization Adopts a QI Mindset, then Upper-level Management will 1. Establish the importance of QI 2. Educate the organization’s leadership 3. Set clear roles and responsibilities for individuals on the team G. Many healthcare organizations have implemented the Model for Improvement. 1. Involves testing changes through the plan-do-study-act cycle where improvement changes can be evaluated for effectiveness and issues before being adopted by the entire organization 2. Other popular frameworks are Six Sigma, Lean, and Lean Six Sigma, which focus on removing waste, duplication, and non–value-added steps in a process. Box 1. Deming’s 14 Points for Manufacturing Quality Improvement 1. “Create constancy of purpose toward improvement.” Think long-term planning, not short-term reaction 2. “Adopt the new philosophy.” Management as well as the workforce should actually adopt this philosophy 3. “Cease dependence on inspection.” If variation is reduced, there is no need for inspection because defects (errors) will be reduced or eliminated 4. “Move toward a single supplier for any one item.” Having multiple suppliers means increased variation 5. “Improve constantly and forever.” Focus on continuous quality improvement 6. “Institute training on the job.” Lack of training leads to variation among workers 7. “Institute leadership.” This draws the distinction between leadership, which focuses on vision and models, and supervision, which focuses on meeting specific deliverables 8. “Drive out fear.” Management through fear is counterproductive and prevents workers from acting in the organization’s best interests 9. “Break down barriers between departments.” Eliminate silos. All departments are interdependent and become each other’s customers in producing outputs 10. “Eliminate slogans.” It is not people who make most mistakes – it is the process in which they are working 11. “Eliminate management by objectives.” Production targets encourage shortcuts and the delivery of poor-quality goods 12. “Remove barriers to pride of workmanship.” This leads to increased worker satisfaction 13. “Institute education and self-improvement” 14. “The transformation is everyone’s job” H. Individuals and teams require training to meet challenges and overcome barriers. 1. QI tenets, skills, and tools 2. Personal attributes needed include enthusiasm, curiosity, and collaboration. 3. Training resource: Institute for Healthcare Improvement 4. Essential tools (Table 1) ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-8 Healthcare Systems and Population Health Table 1. Essential Tools for QI Tool Cause-and-effect diagram (i.e., Ishikawa or fishbone diagram) Driver diagram Failure Mode and Effects Analysis (FMEA) Flowchart, Process mapping Histogram Pareto chart (80/20 rule) Plan-do-study-act cycle Project planning Run chart (control chart) Scatter diagram Use Graphically displays relationships of many causes contributing to an outcome Visual display of what primary and secondary items contribute to achievement of an aim Predicts where, how, and to what extent a system failure could occur so that improvements can be devised to prevent the failure Visual map of the steps in a process Displays continuous data over time to reveal variation Bar chart of contributing factors arranged from largest to smallest Documents testing a change Systematically plans the changes to be tested Graphs data over time (run chart) and, with the addition of upper and lower control limits (control chart), helps distinguish causes of variation Helps identify cause-and-effect relationships between two variables III. TECHNOLOGY A. Dispensing was the initial focus for QI supported by technology. B. Accuracy and Timeliness of dispensing is improved when barcode dispensing, automated dispensing, and other robotic supports are implemented. C. These dispensing systems also allow improved management of inventory, which reduces cost. D. Evolution of the electronic health or electronic medical record added other patient safety features. E. Computerized Order Entry and Electronic Medical Records 1. Dispensing 2. Administration systems, helping to ensure the right drug is administered to the right patient at the right time 3. Intelligent infusion devices 4. Incorporating clinical decision support systems to help prescribers select the right drug at the right dose and help the organization meet important quality indicators 5. Implementation of QI programs and projects with ease of data collection 6. Surveillance of antibiotic prescribing, opioid prescribing, and adverse drug events (ADEs) a. Timely when reports are generated by electronic health records b. Allow implementation opportunities for intervention in real time to increase patient safety F. Automatic Capture and Reporting of Information 1. Identify patients who require review and intervention, such as laboratory values and dosing issues 2. Documentation and management tools 3. Reporting pharmacy/pharmacist metrics and patient outcomes data ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-9 Healthcare Systems and Population Health G. Telepharmacy: Improves access, outcomes, and patient safety H. Online Access to Medical Records 1. Exceeded the Healthy People 2030 goal 2. Patients can better track and manage their health care with this access IV. QUALITY MEDICATION USE IN HEALTHCARE SYSTEMS A. Formulary Systems 1. One of the first quality initiatives used by healthcare systems 2. A formulary is defined as a continually updated list of medications. 3. Standardizing the list of medications for use a. Reduces variability in practices b. Improves efficiencies 4. TJC standard on medication management requires hospitals to develop and approve criteria for identifying formulary medications. 5. Criteria include indications for use, effectiveness considerations, drug interactions, ADEs, potential for errors and sentinel events, other risks, and costs. 6. The P&T committee is usually delegated responsibility for implementing this standard and any associated policies and procedures. Formulary management tools used by the P&T committee usually include: a. Preference for generic drugs b. Restricted/prior authorization for use of specific drugs c. Policy/procedure to obtain non-formulary agents d. Therapeutic interchange according to protocol e. Medication use criteria B. Medication Use Evaluations 1. Evaluation of medication use processes and outcomes 2. Goal is to improve safety, effectiveness, and costs. 3. May evaluate any or all steps of medication use process, including prescribing, dispensing, administration, monitoring, and system management 4. Medication use evaluations are part of an interprofessional QI program. 5. Responsibility of the P&T committee C. Surveillance in the Healthcare System 1. Antibiotic stewardship a. Required for hospitals, critical access hospitals, and nursing care centers by TJC as of 2017 b. The standard addresses concerns with antibiotic resistance and the reported unnecessary use of antimicrobials (up to 50% of antibiotic prescriptions). c. CDC Core Elements of Hospital Antibiotic Stewardship Programs ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-10 Healthcare Systems and Population Health Figure 1. CDC Core Elements of Hospital Antibiotic Stewardship Programs. Source: CDC. Core Elements of Hospital Stewardship Programs. US Department of Health and Human Services. CDC, 2019. Available at https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf. CDC Disclaimer: Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention. This material is available on the agency website for no charge. d. Resources found on the Infectious Diseases Society of America website: i. Describe the purpose of these programs to be in compliance with evidence-based guidelines for antimicrobial prescribing ii. Also name the personnel required to include a pharmacist trained in infectious diseases together with a physician (preference for infectious disease education/training), a microbiologist, and an infection control expert e. Required surveillance monitoring includes: i. Identifying patients with redundant antimicrobial coverage ii. Overall antimicrobial use on a quarterly basis iii. Daily review of antibiotics from a proposed list of restricted-use agents iv.  Daily activities should also include escalation and de-escalation of pathogen coverage, intravenous-to-oral conversions, pharmacokinetic monitoring, and renal dose adjustments. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-11 Healthcare Systems and Population Health 2. ADR reporting a. ADRs, ADEs, and medication errors are related and overlap (Table 2). b. ADR reporting developed as a means of postmarketing surveillance for the FDA. c. Required reporting by manufacturers; voluntary for clinicians, patients d. All ADRs are ADEs, but the ADE definition includes overdose. Some also include omission or underdose of an indicated drug as ADEs. e. Medication errors initially focused on deviations in dispensing and administering from the prescribed order/prescription. Now also include errors in prescribing and monitoring i. May result in patient harm ii. Useful to monitor for system defects iii. “Near misses” may also be reported where error was caught before it reached the patient. f. ADEs came to the forefront in the United States when the Institute of Medicine published “To Err Is Human.” i. This report highlighted that up to 50% of ADEs are the result of unsafe medication use. ii. Estimated costs associated with ADEs include 350,000 hospitalizations and 1 million ED visits annually. g. Newer systematic review of ADR studies indicates 16% of hospitalized older adults experience an ADR and more than 50% of these ADRs were judged preventable h. Technology allows for reporting and analysis of ADRs in large databases to identify areas for improvement i. Hospitals and healthcare systems must have policies and procedures for reporting and evaluating ADEs. j. Tools and resources are available to assess, prevent, and resolve ADEs. i. Naranjo algorithm includes 10 questions to standardize assessment of the probability that a drug caused a clinical event. ii. Root cause analysis involves reconstruction of the occurrence of an error and multidisciplinary analysis of how and why it happened. Table 2. ADRs, ADEs, and Medication Errors Term Adverse drug reaction (ADR) Adverse drug event (ADE) Medication error 3. Definition Any response to a drug at doses normally used in humans Tools/Notes Reported through MedWatch (drugs) and VAERS (vaccines); Naranjo algorithm and WHO Uppsala Monitoring Centre Scale assess causality An injury resulting from a medical National Action Plan for ADE Prevention goals intervention related to a drug to identify significant ADEs and align efforts to reduce ADEs Any preventable event that may cause Most do not lead to significant patient harm or lead to inappropriate medication Those that do are also classified as ADRs or use or patient harm while the medication is in the control of the ADEs healthcare professional, patient, or consumer Pain assessment and management a. TJC requires surveillance activities. b. Opioid stewardship programs are an effective way to ensure a facility is meeting these standards. c. In states where prescription drug monitoring programs must be consulted before prescribing opioids, accreditation surveyors will ensure compliance with state law. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-12 AL GRAWANY Healthcare Systems and Population Health V. POPULATION HEALTH A. Public health is the science of preventing disease, prolonging life, and promoting wellness in a population through organized efforts by local, state, and national governments that are accountable to the community. 1. Links science with actions for a population 2. Involves research, education and policy to achieve improved outcomes 3. Pharmacists are often overlooked as contributors to population health. B. Population health is also focused on the health of a population rather than each individual person. 1. Includes social and economic factors that contribute to a population’s health 2. Efforts may be government-run but are also run by hospitals or volunteer organizations. C. Population health management refers to the steps taken by healthcare organizations to improve the health outcomes of a defined group of individuals. D. Population Health Management Cornerstones 1.  Disease surveillance 2.  Disease prevention: a.  Immunizations b.  Health screenings 3.  Preventive medicine 4. Emergency preparedness E. Disease Surveillance 1. First established in the context of public health before being applied to medication use within a health system 2. Ongoing systematic collection, analysis, and interpretation of health-related data essential to planning, implementing, and evaluating public health practice. Timely dissemination of the data, analysis, and interpretation is needed to prompt action by public health professionals, government leaders, and the public. 3. The recent COVID-19 pandemic is an example of active disease surveillance that changed practice rapidly as new information was obtained. 4. Pharmacists became important sources of information as recommended vaccinations and monoclonal antibody administration were provided in local pharmacies and hospitals. 5. Pharmacists reported informally on the use of non-approved therapies (i.e., hydroxychloroquine, ivermectin). F. Disease Prevention: Immunizations 1. Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) to the CDC 2. Immunization schedules published by the CDC annually after review 3. Schedules are divided by age: a. Children (birth to age 18) b. Adults 19 years and older c. Recommendations for travelers and pregnant women are available on the CDC website. d. Includes medical conditions, comorbidities, special situations, contraindications, and precautions to guide health care provider recommendations ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-13 Healthcare Systems and Population Health 4. U.S. pharmacists can vaccinate patients: a. Laws vary from state to state with respect to regulations on patient ages, vaccines, and need for a prescription. b. APhA maintains vital information on storage and administration of vaccines for pharmacists providing vaccinations on its immunization center website. c. Immunization Action Coalition (www.immunize.org) provides information for health care providers, the public, and immunization coalitions. G. Disease Prevention: Health Screenings 1. Health screenings recommended by the USPSTF a. An independent, volunteer panel of experts b. Develops evidence-based recommendations c. Focuses on clinical preventive services apart from immunizations 2. USPSTF website recommendations are categorized for patients by age, sex, pregnancy status, grade, category of disease/condition, and type of service. 3. Thirteen recommended items involve counseling, 10 are for preventive medications, and 29 are for screening. Screening may require laboratory procedures or questionnaires. H. Preventive Medicine 1. May be targeted for one patient at a time or focus on populations at any level: a. Insured lives, b. Employees of a company, or c. Members of a community 2. State- and national-level disease prevention may involve laws and regulations of businesses, manufacturers, health professionals, and highways. 3. States, nations, and international organizations offer voluntary opportunities for disease prevention. 4. Disease prevention activities are categorized as primary, secondary, or tertiary (Table 3). Pharmacists are involved in each of these areas with providing medications and patient counseling and reporting trends to public health entities. Table 3. Types of Disease Prevention Level of Disease Prevention Primary Secondary Tertiary Patient or Population Focus Aim Examples General population or a specific at-risk population before the disease develops Individuals exposed to or with early disease before morbidity occurs Reduce exposure to risk factors and increase resistance to disease, thereby decreasing the number of cases Provide postexposure prophylaxis or early treatment before symptoms are identified Immunizations Patients with disease causing morbidity Reduce morbidity/mortality and return individual to better state of health Awareness campaigns Antiviral agents for nursing home residents in an influenza outbreak Colonoscopy screening after age 45 Support groups to improve adherence to diabetes treatment to prevent blindness Availability of antivirals for influenza to prevent pneumonia, hospitalization, and death ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-14 Healthcare Systems and Population Health VI. EMERGENCY PREPAREDNESS 1.  isasters are sudden ecological phenomena of sufficient magnitude to require external assistance. D Disasters may be natural or manmade, though most are natural. a. Natural disasters are forces of nature that are typically: i. Meteorological events caused by severe weather (most common) ii. Geologic events (earthquakes, volcanoes) iii. Celestial events (asteroids, solar flares) iv. Biological disasters (epidemics) b. Some disasters are manmade, though natural occurrences may also cause them: i. Radiation/chemical leaks, structural failures, or wildfires accidentally caused by humans ii. Technologic disasters, including power interruptions iii. Terrorism events have increased over the past 100 years. 2. Although no community can be prepared for every emergency, lack of planning results in lives lost. 3.  Regularly scheduled hazard vulnerability analyses are performed by emergency preparedness professionals. a. State and local health departments b. Federal Emergency Management Agency (FEMA) 4. Identify a community’s highest risk of disaster so that appropriate plans can be developed a. Trust for America’s Health report “Ready or Not 2022” evaluated 10 indicators of emergency preparedness to rank states’ level of preparedness. b. Most states have: i. Plans to expand healthcare capacity in an emergency ii. Public health and emergency management accreditations iii. Safe water c. Many are not prepared with i. Workforce resiliency including paid time off for illness or caring for family member, which was highlighted during the pandemic ii. Percentage of people vaccinated iii. Meeting patient safety standards d. Seventeen states have a high level of preparedness, which decreased from 2021. Thirteen states have a low level, and the rest rate in the middle tier. e. The WHO and the CDC agree that the United States is ill-prepared for many emergencies. f. Preparation requires i. Surge capacity anticipated for both personnel, space, and supplies ii. Supplies stockpiled with appropriate rotation to prevent expiration iii. A communication system with both primary and backup systems in case of primary system failure iv. Routine emergency drills to prepare employees and identify weaknesses in the response plan should occur routinely. (a) Simulated emergency response in the community (b) Tabletop drills to walk through steps in the plan 5. Well-trained pharmacists are essential when disasters occur and emergency plans are set in motion. a. Pharmacist roles most often involve procurement and distribution of medications, mass immunizations, and antibiotic dispensing. b. Support to their local community c. Mobilization with organizations like the American Red Cross, the National Pharmacy Response Team, and the Disaster Medical Assistance Team ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-15 Healthcare Systems and Population Health VII. COMMUNICATION AND EDUCATION FOR PROVIDERS AND STAFF A. Evidence Supporting Teaching, Precepting, and Learning 1. Pharmacists need to be familiar with evidence that supports didactic and precepting strategies used in health professionals’ education. 2. To promote the best learning outcomes, teachers, preceptors, and administrators need to use evidence, not only in the content of what is taught or practiced but also in the process of teaching and learning (Box 2). Box 2. Key Findings from Research That Can Inform Your Teaching and Precepting 1. Good teaching and precepting can promote better learning outcomes 2. A  one-size-fits-all approach to teaching and learning does not work as well as multiple strategies 3. M  illennials and younger generations are not as satisfied with traditional learning approaches, so their learning potential may be better achieved with more current strategies a. Their K–12 education has evolved to include more technology and newer approaches to teaching and learning b. Society’s culture has evolved rapidly, whereas higher education has not 4. A student-centered model promotes better learning outcomes than a teachercentered model 5. Instructional alignment can promote better learning outcomes 6. Active learning promotes better learning outcomes (e.g., retention, application) than passive learning (e.g., sitting in a lecture, possibly even with note taking) 7. Long lectures (even as short as 50 min) do not hold students’ attention as well as short, punctuated lectures 8. Providing context and establishing relationships to practice and other content areas promotes better learning (e.g., vertical and horizontal integration) 9. Thoughtful repetition and scaffolding (i.e., going from simple to complex in a logical sequence) can promote better learning outcomes 10. Using readings with targeted questions or guides promotes better learning outcomes than assigned readings alone 11. Frequent assessment with feedback leads to better learning outcomes 12. Specific, objective, immediate feedback can improve learning outcomes 13. Critical thinking is best developed through modeling and demonstration 14. Writing improves critical thinking and learning retention and application B. The main educational frameworks and guiding philosophies currently used in academic settings are learnercentered vs. teacher-centered teaching. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-16 Healthcare Systems and Population Health C. These are defined by their focus: 1. What the student is learning 2. How the student is learning 3. The conditions under which the student is learning 4. Whether the student is retaining or applying the learning 5. How current learning prepares the student for future learning D. Table 4 shows characteristics. Table 4. Characteristics of Teacher- and Learner-Centered Education Models Teaching Paradigm Stored knowledge model Content centered Instructor oriented Didactic teaching Professional training Learning Paradigm Constructed knowledge model Ability centered Student oriented Active, experiential learning Professional education Adapted from: Zlatic TD. Re-visioning Professional Education: An Orientation to Teaching. American College of Clinical Pharmacy, 2005. E. When designing educational programming, Bloom’s taxonomy is often incorporated as a way to design, assess, and diagnose student learning. F. Educational psychologist Benjamin Bloom and colleagues originally defined levels of learning for three different learning domains (Figure 2). Figure 2. Bloom and Krathwohl’s taxonomy of learning. Information from: Krathwohl DR. A revision of Bloom’s taxonomy: an overview. Theory Pract 2002;41:212-8. G. The cognitive domain is the most widely used domain in education. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-17 Healthcare Systems and Population Health H. These taxonomies can be extremely helpful when creating objectives, instruction, and assessments (e.g., examination questions) designed to tap into specific levels of learning (Figure 3). Figure 3. Bloom’s cognitive taxonomy (levels with numbers), associated verbs used for objectives (inner set of words), and potential instructional strategies to achieve those objectives (outer set of words). Information from: Krathwohl DR. A revision of Bloom’s taxonomy: an overview. Theory Pract 2002;41:212-8. VIII. BARRIERS IN COMMUNICATION WITH PATIENTS AND CAREGIVERS A. The most often-cited barriers in communicating with patients and caregivers include the poor health literacy of many patients and the lack of cultural competency exhibited by pharmacists and other clinicians. B. Health Literacy 1. Defined as how well a patient can obtain, process, and understand basic health information when needed to make a decision. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-18 Healthcare Systems and Population Health 2. Ability to read is essential, but health-related materials require additional comprehension. 3. Low health literacy influences health disparities, reducing a patient’s disease knowledge and health status and use of health services, including preventive care. It is associated with: i. Increased visits to hospital and emergency department ii. Decreased mammography iii. Decreased influenza vaccination 4. Medical expenditures and mortality are increased in groups with low health literacy. 5. Patients likely to have low health literacy include: a. Those living in poverty b. Those who do not speak English as a first language c. Adults older than 65 6. Access to information, health care services, and financial support has increasingly moved to an electronic format, which may add another barrier. 7. Healthy People 2030 added an objective to increase the health literacy of the population (in research status) 8. Five other specific objectives related to health literacy are: i. Increase proportion of health care providers who check patient understanding ii. Decrease proportion of health care providers with poor patient communication iii. Increase proportion of health care providers who involve patients in decision-making as much as they want iv. Increase proportion of people who say online medical record is easy to understand v. Increase proportion of adults with limited English proficiency who say their providers explain things clearly (in developmental stage) 9. Patients with low health literacy are adept at hiding it from providers. Many feel stigmatized if identified. 10. Controversy exists on whether to use surveys and questionnaires in clinical practice to identify patients with low health literacy because of the risk of shaming the individual. a. May use a one-question screening to help avoid stigma b. Example questions for one-question screening: i. Do you have trouble learning about their condition? ii. Do you feel confident filling out medical forms? iii. Do you rely on someone else to help read hospital materials? 11. Use of universal precautions is also a preferred method, which includes: a. Approach all patients as if they are at risk of not understanding health information b. Use a range of strategies for clear communication c. Confirm that patients understand what providers are saying 12. Health organizations should adopt policies and procedures that support productive interactions and improve outcomes in the communities they serve. C. Cultural Competency 1. Many definitions since the term was first used in the 1980s a. At first, the term addressed disparities in health outcomes and was used to improve clinicians’ ability to care for patients of different racial and ethnic groups. Outcome disparities in many disease states were identified at that time, including myocardial infarction and breast cancer. b. Currently, diversity is often used in place of the term cultural competency to reflect the many facets of cultural and individual differences. c. The cultural competency of teams and organizations is part of the definition as policy changes provide necessary support to further enable clinicians to provide culturally appropriate care to patients. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-19 Healthcare Systems and Population Health d. The Office of Minority Health has published standards for providing services that are culturally and linguistically appropriate. i. CLAS (culturally and linguistically appropriate services) includes three areas: (a) Culturally competent care (b) Language access services (c) Organizational supports for cultural competence ii. TJC and other accrediting bodies support organizational adoption of these elements. 2. Assessment tools are available for both individuals and organizations. 3. Understanding a clinician’s own culture as well as the clinician’s patient’s culture enables incorporation of a shared perspective into the care plan. 4. Several models identify aspects of culture that usually influence individuals and their choices such as age, generation, nationality, race, color, sex, and religion. The ETHNIC(S) framework provides clinicians with a handy tool that can help honor a patient’s culture during an encounter (Table 5). Table 5. ETHNIC(S) Framework Cultural Aspect Explanation Treatment Healers Negotiation Intervention Collaboration Spirituality Direct Question or Statement to Be Asked or Stated (use the patient’s phraseology) Why do you think you have this symptom/illness/condition? What have you tried for this symptom/illness/condition? Have you sought any advice from folk healers? Negotiate mutually acceptable options Agree on an intervention Collaborate with patient, family, and healers What role does your spiritual life play? 5. The platinum rule states: “Treat others as they would want to be treated.” Keeping this in mind will help clinicians implement health literacy and cultural competency actions to overcome these types of barriers. D. Teach-Back and Motivational Interviewing Modalities and Techniques 1. Useful tools to ensure patients understand the information they have been given and can use any devices provided 2. Useful for patients regardless of their level of health literacy 3. Up to 80% of medical information received during an office visit is forgotten immediately, and 50% of what is retained is incorrect. 4. Using the teach-back method promotes adherence, quality, and patient safety. 5. Patients will be more accepting if the clinician: a. Is checking that things were explained clearly b. Asks patients to explain back in their own words what they heard or understand about what was said 6. Motivational interviewing a. Evidence-based, patient-centered method of communicating that increases the likelihood of a desired change in behavior b. Motivational interviewing respects the patient’s autonomy and builds the patient’s self-efficacy. c. Autonomy can be supported using open-ended questions, setting an agenda, and asking permission before giving advice. d. Self-efficacy emerges when patients identify incremental changes they are willing to make. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-20 Healthcare Systems and Population Health 7. Five main communication principles are at the core of motivational interviewing together with other micro skills, assumptions (Table 6). These are not natural to most pharmacists and should be practiced. Table 6. Motivational Interviewing Principles Principle Expressing empathy Developing discrepancy Supporting self-efficacy Rolling with resistance Avoiding argumentation Application Example Listen to a patient expressing disbelief, fear, or anger and validate that feeling “It sounds like you find this…” Create a thought-provoking discord for a resistant or ambivalent patient to begin to think about change. Sometimes repeating pros and cons stated by the patient or pointing out the disconnect between goals a patient has stated and their actions “So, on the one hand, you want to control your disease, but on the other hand, you don’t like to take so many pills” Building a patient’s confidence in the ability to make and sustain a change without overpraising. Focus on the behavior “It’s great to see you were able to…” Avoid reacting negatively to a patient’s resistant statements, and use them to explore the patient’s reasons with open-ended questions “Tell me more about that” Practice ignoring antagonistic statements made by the patient. Remind the patient that you are on their side and will be available whenever they want to make a change “May I tell you about my concerns for your health (if you continue to or if you don’t start…)?” IX. CONCLUSION  ealthcare systems and institutions have a responsibility to provide quality medication use for the patients they H serve. This requires pharmacists to have knowledge and skills in use of QI, technology, formulary systems, medication use evaluations, and surveillance. Similar abilities are needed to meet the needs for population health, including disease surveillance, immunizations, preventive medicine, and emergency preparedness. Finally, to achieve optimal outcomes, excellent skills in teaching and learning are required to overcome barriers when communicating with other healthcare professionals, patients, and policy-makers. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-21