wound care benchmarking in community...

WOUND CARE BENCHMARKING IN COMMUNITY PHARMACY –PILOTING A

METHOD OF QA INDICATOR DEVELOPMENT

Project conducted by Therapeutics Research Unit, University of Queensland, Princess Alexandra Hospital

in conjunction with the Department of Pharmacy Practice, Monash University and the Australian Institute of Pharmacy Management

October 2003 Revised January 2004

This project was funded by the Australian Government Department of Health and Ageing as part of the Third Community Pharmacy Agreement through the Third Community Pharmacy Agreement Research and Development Grants (CPA R&D Grants) Program managed

by the Pharmacy Guild of Australia

ISBN 186499823

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PREFACE We are grateful to the Third Community Pharmacy Agreement Research and Development Grants (CPA R&D Grants) Program for giving us the opportunity to explore issues of measurement and service quality in community pharmacy. This preliminary work has shown that it is possible to develop “rulers” for measuring the services provided by community pharmacies. The study has also identified a number of needs for wound care and emphasised the challenge before community pharmacy to measure the health outcomes of the services provided. We wish to acknowledge the contributions of the Expert Panel to this project. Panel members gave freely of their time and expertise. Thanks are also due to the owners and staff of the pharmacies taking part in the pilot study. They too, were generous with their time and assistance, at a time when they were coping with the largest recall of pharmaceutical products Australia has ever seen. We would also like to thank Bruce Annabel, from Johnston Rorke Pharmacy Services, who generously provided data on the financial performance of some pharmacies in the wound care category. Julie Stokes Michael Roberts Sheree Cross John Chapman Greg Duncan

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EXECUTIVE SUMMARY AIMS This project sought to define a set of quality service indicators to assist community pharmacists with self-assessment of their provision of a quality wound care service. This project also sought to relate these indicators to the current practice of wound care provision in community pharmacies so that pharmacies could identify areas for improvement as part of a continuous quality improvement process.

DESCRIPTION OF THE PROJECT The overall study methodology is summarised in Figure. 1.

Establish “expert panel”

Likely stakeholder contributions:• Brainstorm possible indicators• Current pharmacy wound care practices & data availability• Feasibility of applying draft indicators as part of pharmacy practice• Quality issues of concern to, and methods to collect data from consumers & other health professionals• Specific aspects of quality wound care (what indicates “quality-in-fact”?)• Outcome assessment eg. Improved wound healing• Secondary sources of dressing use/sales data• Alternative strategies to facilitate data collection eg. Point-of-sale or dispensing computer• Dissemination of results & implementation within political framework

Advise on:

Develop draft indicators from:• Literature• Current studies• Expert consultationConsider method of measurement

and data capture

Multidisciplinary expert panel to:• Review draft indicators and methods

of measurement/data capture for relevance & feasibility

• consider possible standards for level of compliance with indicators

Examples of possible indicators:• Rate of wound healing assessed through patient follow-up• Pharmacist & pharmacy staff knowledge about wound care

& wound type recognition• Ongoing specific staff training/education • Ratios of wound care products stocked or sold (eg.

interactive vs passive dressings) • Number of referrals for wound care products/advice to &

from other health professionals• Patient satisfaction• Possible methodologies include guided self-audit process,

consumer survey, secondary data collection from wholesalers

Pilot indicators - (June-Oct 2002)• 15 pharmacies - purposive, non-

random sample• Include pharmacies with known

high quality service

Pharmacies to run indicator program• Capture data required for indicators• Gain any consumer consent required• Repeat data collection as required• Include audit and test-retest

Evaluation of indicators and indicator development methodology for feasibility, practicality, generalisability and cost effectiveness

Analysis of:• Indicator data comparing between

high, moderate and basic quality services

• Pilot pharmacy feedback on process

Feedback results of pilot to expert panel

Revise indicator setfor dissemination and inclusion in QCPP program

Figure 1 Overall study methodology

In brief, the set of quality service indicators for a quality wound care service by community pharmacists were developed as follows: • A multidisciplinary expert panel was formed to develop the indicators. The panel consisted

of representatives from community pharmacies and staff, consumers, general practitioners, vascular medicine, community nurses, podiatrists, consumers organisations e.g. Diabetes Australia, wound care product manufacturers and medical researchers (Chapter 4)

• This panel used published literature, current studies, manufacturer data and expert advice to develop a best practice wound care flow chart for community pharmacy and a resulting set of draft indicators (Chapter 5)

• Assessment of the indicators was undertaken in a pilot study of 14 community pharmacies (Chapter 6.2). The following sets of data were collected: • characteristics, stock holdings, sales and wound service care provision reported by the

community pharmacy • independent audit of pharmacy wound care section by a pharmacy researcher

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• an assessment of service quality by an independent mystery shopper • a consumer telephone survey • semi-structured interviews with pharmacies after pilot study data collection

• The potential quality indicators were then evaluated against an independent measure of service quality in the pharmacies (Chapter 6.3). The performance of the indicators as part of a self-audit or benchmarking process was studied for feasibility, practicality, generalisability and cost-effectiveness.

KEY FINDINGS 1. Participating community pharmacy characteristics. 14 community pharmacies of a

possible 35 screened participated in this study, the majority of those failing to do so citing timing and staffing issues (Chapter 7.1).

2. Need for wound care products in pharmacy. The pharmacies in this study saw a median of one wound care customer a day (excludes sprains, strains and sports injuries). Cuts and grazes were the most common wounds (35%) followed by stitches and surgical wounds (20%), burns (15%) and leg ulcers or pressure sores (12%) (8.1.7). Wound care products represented less than 2% of turnover for 70% of the pharmacies surveyed. The percentage of turnover from wound care at the sites in the study ranged from less than 1% (45% of sites) to more than 5% (9% of sites) with a median level at 1-2% (8.1.3.2). Higher turnover was associated with greater sales of advanced dressings (Figure 8.24).

3. Space used for wound care in pharmacy. Total linear metres of shelving taken up by dressings was a median of 5.4m for smaller pharmacies (less than 200m2) and 10.0m for larger pharmacies (>200m2) with wound care products (not first aid, tapes and bandages) occupying a median of 64% and 50% of this shelving respectively (Table 8.1). The sizes, shapes and bulk of these products created difficulties for pharmacies in merchandising this pharmacy category (8.1.1.1 and 7.3).

4. Wound Care services by pharmacy assistants. Wound care services in community pharmacy are generally provided by pharmacy assistants, with pharmacists being consulted for about one quarter of wound care customers (9.3.3.) in pharmacies providing the level of wound care service commonly seen in community pharmacy. Pharmacy assistants have a lack of confidence in dealing with wound care customers particularly in situations where their lack of knowledge is highlighted (7.3 and 7.4). Pharmacy assistants with better knowledge are better able to influence customers (8.1.3) and better pharmacy assistant knowledge is also associated with better service quality (8.3.4 and Table 1).

5. Customer satisfaction with wound care service. From the limited number of subjects recruited to the customer survey, the majority of customers rated the pharmacies as excellent in meeting their overall wound care needs (5 of 9) (Table 8.20) and based on customer recall, advice was given in 55% of these transactions, in 1 case, written information. More than 60% of pharmacies had written information on wound care available for their customers but the customer survey suggests that this written information is not routinely provided.

6. Pharmacists perceptions inconsistent with practice. Proprietors’ estimates or impressions of characteristics of their wound care service are not always a good reflection of the actual characteristics e.g. types of wound seen, staff training, how often the pharmacist is consulted, referral rates and service quality (sections 8.1.2.2, 8.1.3 and 8.1.7). Prospective data such as a customer log or objective information such as a staff training registered would provide more reliable information about the service.

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7. Need for standard operating procedures. Availability of written policies or procedures in areas such as products kept, advice to customers on product use, staff training, skills, knowledge and resource maintenance, and referral to other health professionals to support wound care services was low (8.1.2.5). The level of documentation of the wound care services e.g. wound history, wound follow-up and monitoring, was also low. There is a need for independent tools, guidelines and protocols to help pharmacy staff consult the pharmacist where appropriate, initiate referral, to guide customers on appropriate product selection and to offer advice on the appropriate use of products (7.3 and 7.4).

8. Rural pharmacies have a greater need for support. There is some evidence that the demands on rural pharmacies for wound care services are greater than on an average metropolitan community pharmacy since there are fewer alternative service providers, as evidenced by the broader stock range carried (Figure 8.5) and greater levels of more advanced dressings (Table 8.3). These pharmacies also find it more difficult to access training for staff and pharmacists find it more difficult to find locum cover for training courses in the city (7.3).

9. Need to increase use of advanced dressings. Only 35% of products sold were more advanced dressings but the median appropriateness rating of dressings sold was equivalent to “Limited potential to help healing” (8.1.7). Pharmacies carry large quantities of passive and first aid dressings (and associated tapes and bandages), often therapeutically equivalent dressings, and these dressings represent 65% of sales (8.1.5 and 8.1.7). As part of improving wound care, pharmacies need to increase the proportion of more advanced dressings sold to have a greater impact on wound healing.

10. Influential role of manufacturers. Wound care product manufactures exert a strong influence on the merchandising display (8.1.1.1), product range carried (8.1.2.3) and as providers or information and training (8.1.2.4 and 7.3).

11. Need for wound care training for pharmacy staff. Pharmacy assistants reported influencing customer product selection in 61% of cases but the appropriateness of products sold was often low. Wound care education currency and quality varied greatly between pharmacies (9.3.1). Currently, some pharmacy assistants have difficulty accessing training and those that receive training report that the content is sometimes “over our heads” and does not seem to have relevance in the way that they carry out their work (7.3). There is also a need for pharmacist wound care training - in 1/3 of pharmacies, pharmacists had received no wound care training in the last 2 years and pharmacist wound care knowledge was associated with service quality measures (Table 1).

12. Independent measures of service quality (9.4). Lack of information seeking or advice as assessed by a mystery shopper was a major limitation in current community pharmacy wound care practice. In general, adequate wound care resourcing was perceived by the independent auditor but a customer log suggested that the products selected were inappropriate. Expressed in terms of a combined quality scores, pharmacies could be categorised as being: a. in urgent need of improvement, b. offering a basic service, c. providing an intermediate service and d. advanced service, the latter being met by a single site.

Various indicators could be related to quality measures as shown in Table 1. Data collection for practice improvement purposes is generally outside usual practice as illustrated by the limitations of point-of-sale systems for this purpose and the difficulty in capturing the outcomes of wound care in community pharmacy, although the need was recognised by participants.

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13. Effectiveness. The expert panel methodology was effective in identifying potential indicators. Of the indicators collected, all were feasible and practical for the majority of sites except for the customer recruitment for the customer survey and the sales/purchases history data and took a median of less than 4 hours of pharmacy time to collate. Some of the measures based on proprietor estimates were less reliable than prospectively collected more objective measures. Indicators also suggest quality improvement actions. Individual pharmacies reported that, by and large, their participation in the pilot as a data collection exercise was beneficial, often in ways unanticipated by the researchers. The cost-effectiveness of using the indicators depends on pharmacies making improvements to services provided and any flow-on effects on wound healing or prevention of complications. Focusing on wound care can be financially worthwhile for individual pharmacies, since the average gross profit margins for this category in a sample of 21 pharmacies was 38% compared to 29-30% commonly seen for the dispensary (data provided by Johnston Rorke Pharmacy Services) (9.8.1).

Table 1 Relationship between indicators and any quality measure

Related to quality measures Not related to quality measures QCPP accreditation (R) – space, facility & display only Size of business entity as indicated by: Opening hours (R) No. prescriptions filled/week (R) No. pharmacists employed (R) No. EFT Pharmacy assistants (R)

(audit aspects not service experience or technical quality) In banner group (A) (yes=poor mystery shopper result)* Providing dressings to other organisations (R) Signage for the wound care area (A) Linear metres of shelving for wound care dressings (A)

and percentage of dressing shelves for wound care (not first aid) products (A) Attention to merchandising other than the use of

manufacturers’ displays (A) Wound care referral to pharmacy from other health

professionals (R) Maintenance of patient wound care records (R) Extent of pharmacy assistant influence on purchase (L) Frequency of pharmacist consultation in a wound care

service episode (L) No. pharmacy assistants with wound care training (R) Pharmacy assistant & pharmacist knowledge scores (Q) Presence of product selection information resources (R) Percentage of patients seeking wound care who had

burns (R & L) and stitches/surgical wounds (L) (negative relationship) Percentage of dressings sold not passive or first aid

dressings, tapes or bandages (L) especially hydrogels, hydrocolloids and alginates Higher percentage of turnover from wound care (R) Overall stock range and stock level (A) and stock range

and level of more specialised dressings

Rural versus metropolitan (A) but trends favour rural if exclude advanced sites* Physical size of pharmacy (A) No. EFT Pharmacists (R) Extent of use of manufacturers’ displays

(A) Total linear metres of dressing shelving

(A) and linear metres of shelving for first aid (A) Availability of written information on

wound care for customers to take away (R) Wound care referrals by pharmacy to

other health professionals (R & L) Wound history taking (R) Monitoring and follow-up of wound

healing (R) Existence of wound care

policies/procedures whether written or unwritten (R) Proportion of opening hours a wound care

trained assistant was on duty (R) Presence of wound assessment

information resources (R) Stock range and stock level of passive

and first aid dressings (A), hydrogels and hydrocolloids

Key for source of data: R=reported by proprietor; A=recorded at independent audit; L=recorded by staff on the customer log; Q=quiz; *=needs further investigation

14. Involving community pharmacies in research. Strategies were identified to overcome barriers to community pharmacies participating in research. The relevance of the project to their practice and the use of research mentors were enablers of this pharmacy research.

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CONCLUSIONS

Currently, pharmacies act passively (by a passive supply of passive dressings). Their opportunity is to become active by selling of active dressings to meet individual customer needs. The recognition by the pharmacists that this research was valuable suggests there is a possibility that the opportunity could be seized by those pharmacies wishing to invest more in direct patient care.

RECOMMENDATIONS Given that future wound care products are likely to emphasize the presence of active medicinal substances, pharmacy has an opportunity to become a dominant supplier in this niche market, the following recommendations relate to improving current services and building capacity to fill a wound care niche. 1. Education of pharmacists and pharmacy assistants in wound care practice must be a priority

if community pharmacy wishes to remain as a credible service provider of wound care advice and products. This education should be at a level and delivered in a way that is relevant to practice.

2. Benchmarking indicators for outcomes of community pharmacy wound care practices should be integrated into pharmacy IT systems as part of an ongoing quality assurance process and to provide evidence on which to base future government negotiations.

3. Benchmarking indicator methodology developed here should be translated into other areas of professional community pharmacy practice.

4. Non-company based simple tools should be provided to community pharmacies to assist in wound care product selection.

5. Protocols and resource booklets need to be developed to enable community pharmacies to better refer and network with local healthcare providers.

6. There is a need to better support rural community pharmacies in enhancing their wound care service.

7. Manufacturers need to pack dressings in sizes more suitable for sale in community pharmacy (e.g. pharmacy packs with 1-3 units/pack).

8. Self-selection by the customer would be facilitated by having basic written instructions for use of more advanced dressings available in the wound care section and by displaying simple visual aids to help customers select the best product or give non-brand specific choices for treatment.

9. There is an opportunity to develop wound care as a specialty practice by: a. A focus on service delivery (stock range and staff knowledge better addressed)

including staff interventions e.g. assistance selection and best use of dressings, customer follow-up of wound healing.

b. appropriate merchandising for self-selection (since customers will still self-select, especially if the pharmacy is busy).

10. Benchmarking indicators could be used to inform future Guild-government agreements so that these organisations could coordinate the collection and analysis of indicators longitudinally.

11. The critical success factors for research in community pharmacy should be recognised and supported by pharmacy organisations. Research projects conducted in community pharmacies should address the critical success factors such as mentoring and this should be allowed and expected as part of the costing of these projects.

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TABLE OF CONTENTS PREFACE ...................................................................................................................................... I EXECUTIVE SUMMARY .............................................................................................................. II

AIMS ............................................................................................................................................II DESCRIPTION OF THE PROJECT......................................................................................................II KEY FINDINGS .............................................................................................................................III

Conclusions ...........................................................................................................................vi RECOMMENDATIONS ................................................................................................................... VI

1. INTRODUCTION AND BACKGROUND............................................................................... 1 1.1 WHY FOCUS ON WOUND CARE? ........................................................................................ 1 1.2 SERVICE QUALITY AND BENCHMARKING IN COMMUNITY PHARMACY..................................... 1 1.3 POSSIBLE WOUND CARE INDICATORS ................................................................................ 3

2. RESEARCH TEAM ............................................................................................................... 4 3. OVERALL STUDY PLAN ..................................................................................................... 5 4. PHASE 1 - ESTABLISH EXPERT PANEL........................................................................... 7

4.1 METHODS........................................................................................................................ 7 4.2 RESULTS......................................................................................................................... 7

5. PHASE 2 – DEVELOPMENT OF POTENTIAL QUALITY INDICATORS............................ 9 5.1 METHODS........................................................................................................................ 9

5.1.1 First Expert Panel meeting .................................................................................... 9 5.1.2 Development of wound care service best practice model..................................... 9 5.1.3 Development of pilot study protocol .................................................................... 10

5.2 RESULTS....................................................................................................................... 10 5.2.1 Community pharmacy wound care service best practice model ......................... 10 5.2.2 Data collection tools developed for pilot study .................................................... 14 5.2.3 Pilot study protocol revision................................................................................. 15

6. PHASE 3 – PILOT STUDY METHODS .............................................................................. 17 6.1 RECRUITMENT ............................................................................................................... 17

6.1.1 Pilot study start-up............................................................................................... 17 6.2 QUALITY INDICATOR DATA COLLECTION ........................................................................... 18

6.2.1 Customer recruitment and survey ....................................................................... 19 6.2.2 Independent audit................................................................................................ 19 6.2.3 Mystery shopper visits ......................................................................................... 19 6.2.4 Post-trial interviews with pharmacies .................................................................. 21

6.3 EVALUATION OF POTENTIAL QUALITY INDICATORS ............................................................ 22 6.3.1 Data preparation.................................................................................................. 22 6.3.2 Independent quality scores ................................................................................. 24 6.3.3 Data analysis ....................................................................................................... 24 6.3.4 Second Expert Panel meeting............................................................................. 25 6.3.5 Feedback of results to participating sites ............................................................ 25

7. RESULTS OF PHASE 3 – CONDUCTING THE PILOT STUDY ....................................... 26 7.1 RECRUITMENT AND STUDY WITHDRAWALS ....................................................................... 26

7.1.1 Contact with sites during pilot study .................................................................... 26 7.2 DATA COLLECTED .......................................................................................................... 27

7.2.1 Time taken to collect data ................................................................................... 28 7.3 POST-PILOT INTERVIEWS ................................................................................................ 29 7.4 SECOND EXPERT PANEL MEETING.................................................................................. 31 7.5 FOLLOW-UP OF FEEDBACK REPORT................................................................................ 32

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8. RESULTS OF PHASE 3 – PILOT STUDY FINDINGS....................................................... 33 8.1 POTENTIAL INDICATOR MEASURES .................................................................................. 33

8.1.1 Audit visit ............................................................................................................. 33 8.1.2 Profile................................................................................................................... 41 8.1.3 Staff Quizzes ....................................................................................................... 52 8.1.4 Stock on hand...................................................................................................... 58 8.1.5 Sales/purchase data............................................................................................ 63 8.1.6 Customer telephone survey ................................................................................ 64 8.1.7 Customer log ....................................................................................................... 67

8.2 DEVELOP INDEPENDENT QUALITY MEASURES................................................................... 78 8.2.1 Mystery shopper visits ......................................................................................... 78 8.2.2 Independent quality scores ................................................................................. 81 8.2.3 Customer telephone survey versus quality rating ............................................... 82

8.3 COMPARISON OF INDICATORS WITH INDEPENDENT QUALITY MEASURES............................. 83 8.3.1 Pharmacy characteristics .................................................................................... 83 8.3.2 Layout of wound care section.............................................................................. 84 8.3.3 Pharmacy characteristics and workload.............................................................. 87 8.3.4 Quizzes................................................................................................................ 98 8.3.5 Customer log ..................................................................................................... 100

9. DISCUSSION .................................................................................................................... 105 9.1 STAKEHOLDERS IN WOUND CARE – MEMBERSHIP OF THE EXPERT PANEL......................... 105 9.2 DEFINING WOUND CARE IN COMMUNITY PHARMACY........................................................ 106 9.3 CHARACTERISTICS OF COMMUNITY PHARMACY WOUND CARE SERVICES ....................... 107

9.3.1 Pharmacy characteristics, staffing and workload .............................................. 107 9.3.2 Layout of wound care section............................................................................ 110 9.3.3 Wound care practices........................................................................................ 110 9.3.4 Proprietors’ perceptions of service quality......................................................... 115

9.4 INDEPENDENT MEASURES OF SERVICE QUALITY ............................................................. 115 9.5 INDICATORS LINKED TO SERVICE QUALITY...................................................................... 117

9.5.1 Pharmacy characteristics, staffing and workload .............................................. 117 9.5.2 Layout of wound care section............................................................................ 119 9.5.3 Wound care practices........................................................................................ 119 9.5.4 Human and information resources .................................................................... 121 9.5.5 Type of wound seen and products provided ..................................................... 121 9.5.6 Stock and sales ................................................................................................. 122 9.5.7 Proprietors’ perceptions of service delivery and quality .................................... 122

9.6 WOUND CARE – AN UNMET NEED IN THE COMMUNITY..................................................... 123 9.7 EFFECTIVENESS OF INDICATOR DEVELOPMENT PROCESS............................................... 125

9.7.1 Where to next? .................................................................................................. 128 9.8 WOUND CARE COST EFFECTIVENESS EVALUATION ......................................................... 130

9.8.1 Pharmacy level .................................................................................................. 130 9.8.2 Health care system level ................................................................................... 130 9.8.3 Assessment of the impact of benchmarking...................................................... 131

9.9 INVOLVING COMMUNITY PHARMACIES IN RESEARCH........................................................ 132 9.9.1 Critical success factors for research in community pharmacy .......................... 132

10. CONCLUSIONS AND RECOMMENDATIONS ............................................................ 134 RECOMMENDATIONS ................................................................................................................ 135

11. REFERENCES.............................................................................................................. 138

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APPENDIX A - MATERIALS FOR FIRST EXPERT PANEL MEETING.................................. A-1 AGENDA FOR WOUND CARE EXPERT PANEL MEETING, 17 APRIL 2002.......................................A-1 MEETING MATERIALS ................................................................................................................A-1

Working materials sent to the Expert Panel after the first meeting ....................................A-3 APPENDIX B – STUDY MATERIALS (PROCEDURES, CONSENT AND DATA COLLECTION FORMS)............................................................................................................ B-1 APPENDIX C – POST TRIAL INTERVIEWS ........................................................................... C-1 APPENDIX D – ETHICAL APPROVAL.................................................................................... D-1 APPENDIX E - MATERIALS FOR FINAL EXPERT PANEL MEETING...................................E-1

AGENDA FOR WOUND CARE EXPERT PANEL MEETING, 30 JUNE 2003........................................E-1 MEETING SUMMARY..................................................................................................................E-2

Presentation of findings to date and discussion.................................................................E-2 APPENDIX F – FEEDBACK REPORT TO PHARMACIES ......................................................F-1

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1. INTRODUCTION AND BACKGROUND This project was proposed as a means of addressing two related imperatives in Australian community pharmacy today. These imperatives are the need to assure and continuously improve service quality, and to demonstrate the value added to the community’s health by community pharmacy. The continuous improvement philosophy of the Quality Care Pharmacy Program (QCPP) will require pharmacists to be able to measure quality in their practices while the ability of community pharmacy to measure the impact of professional pharmacy services will be critical in demonstrating the value of community pharmacy in future Guild-Government negotiations. Central to both quality improvement and any demonstration of value is the issue of measurement. In many areas of community pharmacy there is no single ‘ruler’ against which pharmacies can measure their performance, nor can the performance of many pharmacies be aggregated to present a compelling argument to funding bodies, because if aspects of practice are measured at all, each measurement is made with a different ‘ruler’. At present, there are few feasible and relevant indicators that enable information about service quality and patient outcome to be routinely captured and examined in a community pharmacy setting. Quality cannot be improved if it cannot be measured.

1.1 WHY FOCUS ON WOUND CARE? The current project is about measurement and exploring a methodology that might be used to develop ‘rulers’ for the many and varied areas of community pharmacy practice. While the international literature addresses service quality and outcome for some practice areas such as smoking cessation (Smith, McGhan et al. 1995; Crealey, McElnay et al. 1998; Sinclair, Silcock et al. 1999; Williams, Newsom et al. 2000), wound care is a specific area of community pharmacy practice for which a set of effective quality indicators is not currently available, nor have community pharmacy intervention studies been published. Wound care was selected as a target for indicator development because products and advice on wound care are services consumers expect from community pharmacies (Ortiz, Ledin et al. 1987). Indeed, much of the pharmacy literature about wound care highlights the pharmacist’s role in this area and/or gives pharmacists information to improve their wound care knowledge (Hayward and Morrison 1996; Gasbarro 1998; Sarina 1999). While some pharmacies specialise in this area (Dickson 1997), wound care is a practice area where improvements could be achieved. Further, the scheduling of new biotechnological dressings (e.g. Becaplermin and other growth factors as Schedule 3 or 4 - prescription only in other countries where already available) in the immediate future, will require pharmacies to assess and upgrade the quality of their services.

1.2 SERVICE QUALITY AND BENCHMARKING IN COMMUNITY PHARMACY

High service quality in health care is about delivering services that are appropriate, efficient and effective, resulting in the best outcomes for the clients. This Donabedian view (Donabedian 1980) implies that to provide quality care, professionals are to provide knowledge in such a way as to benefit the clients’ health (Sidani and Braden 1998). In community pharmacy, quality is not just what is provided, but how it is provided. For example, is providing an asthma inhaler, whose active ingredient is known to be effective, without transferring the knowledge about

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proper use of the device a quality service? Community pharmacy must provide appropriate services where those services are based on evidence that the intervention is “of demonstrable effectiveness that are most likely to lead to the outcome desired by the individual patient” (Bowling 1997). The Donabedian model of quality in health care depends on (Sidani and Braden 1998): • Structure: the prerequisites and resources used in the provision of care (includes physical

and organisational work environment, and technical and professional characteristics of care providers). Measuring inputs is a way of operationalising the concept of “structure” (Bowling 1997).

• Process: the actual activity performed and the decision making underlying the performance of that activity; how the service is organised, delivered and used (including interaction between personnel and patients). Process data can include:

o Outputs (the activities that occur through the use of system resources) e.g. number and type of dressing supplied, the length of consultation.

o The quality of relationships and communications e.g. timely referral • Outcome: the end result of care; how effective care was in achieving the intended goal.

Health outcome relates to the impact of the service on the patient (effectiveness) (Bowling 1997) e.g. the changes observed in the client’s health condition, the patient’s evaluation of their health care. Outcome assessments in relation to social care and long term health care in particular, need to measure the difference a service has made to a recipient’s life in the broadest sense (Bowling 1997). Outcome measures can relate to:

o Patients’ perceived health status o Health related quality of life (physical, psychological and social) o Reduced symptoms or toxicity o Patients’ (and carers’) satisfaction or knowledge

The structure and process of services can influence the effectiveness of the service (Bowling 1997). An indicator is a measurable property that varies with the quality criterion to be measured. Indicators must be clearly linked to that quality criterion and be sensitive to different degrees of that criterion (Gillies 1997). Benchmarking is a quality improvement strategy used in many businesses and industries. It involved comparing one business with others, usually industry leaders, across a range of dimensions, often using many techniques. The fundamental question is ‘how does the industry leader approach a particular task compared to how we do it?’. To make these comparisons, data must be compiled in the same way i.e. use the same ‘ruler’. To improve their service, the business undertaking benchmarking would then put into place those practices of the benchmark site that are perceived as contributing to its position as industry leader. In health care, benchmarking is also about health outcomes. As stated by Murphy (Murphy 2000), “benchmarking is a method of comparing the outcomes of health care products, services, and practices at an institution against those of competitors in order to learn what might be improved. Benchmarking programs can provide valuable feedback about both positive and negative outcomes”. The Pharmaceutical Society of Australia has identified benchmarking as one of a range of strategies through which pharmacies can develop systems for quality and safety (2002). Nurses have used benchmarking as a means of improving wound care both in the community and hospital setting (Miller 1996; Newton 1999; Papadopoulos and Jukes 1999). Benchmarking is a voluntary process where the comparator is the industry leader. Quality assessments can also involve comparing the current service against standards that are acceptable

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to patients and health professionals. Comparison against standards is the quality mechanism used in the Quality Care Pharmacy Program. Developing standards for wound care is beyond the scope of this project, but this could be an alternative to benchmarking in a program of quality improvement.

1.3 POSSIBLE WOUND CARE INDICATORS Pharmacist knowledge is only one of a possible range of indicators of service quality. The development of wound care formularies and policies as suggested by others (Morgan 1990; Holloway 1999) could be extended to include indicator and standards development. Such indicators should be supported by evidence, include objective criteria, be practical and easy to apply and used available data. Given the developing nature of information technology in community pharmacy, indicators must also be able to be collected using point-of-sale and/or dispensing or other pharmacy information technology (IT) systems in development. Some work in relation to wound care practices has already been carried out in Australia by others, and work from some of these projects might yield useful and practical quality indicators. In a survey of community pharmacists in Australia, Sussman (Sussman 1998) reported on a self-assessment test of pharmacists’ knowledge of wound management and noted that there was a need to increase knowledge about wound management as part of the project “An audit of wound management practices in Australian Community Pharmacy”. The Community Pharmacy Model Practices Project in South Australia incorporated a wound management model and defined outcomes and standards of practice for the models developed. A recent study by the Wound Education and Research Group at Monash University, “Wound Healing and Cost Impacts of Interventions by Pharmacists in Community Settings”, examined an intervention to improve wound care in community pharmacy and measures therapeutic, economic and quality of life outcomes. Not all the detailed measures used in this study, however, were felt to be useful as ongoing benchmarking indicators for continuous improvement in community pharmacy. Apart from the recent Monash study, no study was located that reported on the impact of community pharmacy on wound care outcomes. The use of a multidisciplinary panel to develop a wound management policy was recommended by Morgan (Morgan 1990) and is a frequently employed methodology in indicator development (Elliott, Woodward et al. 2001). Possible indicators suggested initially were: • Rate of wound healing assessed through patient follow-up • Pharmacist and pharmacy staff knowledge about wound care and wound type recognition • Ongoing specific training and education • The proportion of various wound care products stocked or sold (interactive versus passive

dressings - interactive may indicate professional involvement and recommendation where passive more likely from patient self selection)

• The number of referrals for wound care products/advice to and from other health professionals

• Patient satisfaction • The provision of customer information and education about wound care and use of products • The adoption of procedures to support best practice in wound healing An expected outcome of the project was the development of a set of viable tools to support and trigger a continuous improvement process in community pharmacies. The indicators from the tools could then be incorporated into the QCPP program or be part of a voluntary self-audit/benchmarking exercise by community pharmacies. The pilot study was also expected to identify areas for further intervention studies.

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2. RESEARCH TEAM

Chief Investigator Dr Julie Stokes Qualifications B.Pharm., GDBus(InfoSys), PG Dip Clin Hosp Pharm, PhD Institution and Address: Department of Medicine, University of Queensland, Princess

Alexandra Hospital, Ipswich Road, Buranda, Qld 4102

Principal Investigator . Professor Michael Roberts Qualifications B Pharm, MSc, PhD, D Sc, Dip Tert Ed, MBA, FAIPM; Professor

and NHMRC SPRF Institution and Address: Department of Medicine, University of Queensland, Princess


Principal Investigator . Dr Sheree Cross Qualifications BSc(Hons), PhD Institution and Address: Department of Medicine, University of Queensland, Princess


Principal Investigator3. Mr John Chapman Qualifications B.Pharm, B.Com, PG Dip Clin. Hosp. Pharm Institution and Address: AIPM

Level 1, Pharmacy Guild House, 15 National Circuit Barton ACT 2600, Australia And PhD student, Dept of Medicine, University of Queensland, Princess Alexandra Hospital.

Principal Investigator . Mr Greg Duncan Qualifications B.Pharm, MPH Institution and Address: Department of Pharmacy Practice

Monash University 381 Royal Parade Parkville, VIC 3052

5

3. OVERALL STUDY PLAN The aim of the benchmarking study was to produce a set of indicators suitable for use in benchmarking wound care practices in community pharmacy. We initially proposed to develop a draft set of indicators from the literature and expert consultation, with the draft indicators being reviewed for relevance and feasibility by a multidisciplinary stakeholder working group. The agreed indicator set was to be trialled by a pilot sample of community pharmacies. The performance of the indicators was be examined for feasibility, practicality, generalisability and cost effectiveness. The study had three phases in which to address four aims: (1) To establish an “expert panel” of stakeholders in the wound care services provided by

community pharmacy (Phase 1) (2) To use this panel to generate a range of indicators of wound care service quality (including

patient outcome) that can feasibly be implemented in community pharmacy practice (Phase 2)

(3) To test the practicality and effectiveness of potential indicators in a pilot cross-sectional study as a means of differentiating between different levels of service quality and of identifying specific targets for practice improvement (Phase 3).

(4) To finalise a set of indicators for subsequent testing in an intervention trial (Phase 3) Once an expert panel was established, the plan was to have an initial face-to-face meeting followed by teleconferences and correspondence, to develop a range of possible indicators for piloting, using a modified Delphi technique (gaining consensus using telecommunication in addition to face-to-face communication). At the conclusion of the pilot study, the expert panel was to review the findings of the pilot, examine draft indicators for relevance, feasibility (e.g. availability or ease of obtaining data) and make further recommendations at a second face-to-face meeting. It was anticipated that collection of the indicator data would involve a guided self-audit process and consumer survey (although the pilot study plan was revised as the indicator development process proceeded (5.2.3 and 6.2)). The project would act as a resource for the central collection and analysis of self-audit data and completed consumer surveys, the results of which could be analysed and fed back to the individual participating pharmacies, as the start of a continuous improvement loop. Individual pharmacies would receive an ‘benchmarking’ report that allowed them to compare the results for their own sites with other pharmacies and with a ‘benchmark’ industry leader. The ‘benchmark’ would be determined from within the pilot pharmacies. For any consumer survey, the pharmacies would be asked to inform consumers of the project and undertake the consent process. The project planned to recruit pharmacies representative of a range of practice types (e.g. medical centre, shopping centre and strip pharmacy, metropolitan or rural locations) including a small number of pharmacies known by the Wound Education and Research Group (WERG) to have a high level wound care service. A purposive, non-random sample of 15 pharmacies was originally proposed. A sample size of 15 was felt to be sufficient to demonstrate between pharmacy differences while allowing for adjustment of practice type and limiting the costs of the pilot phase although the subsequent pilot aimed to recruit 20 sites. Victoria was chosen as the area for the pilot study because potential benchmark sites (high level service providers with

6

a previous link to WERG) were known and the logistics of involving rural sites were easier since shorter distances were involved. It was anticipated that data would be collected from the proprietor, staff and customers about possible indicators such as: • The characteristics of the pharmacy including staffing levels, opening hours and layout of

the wound care section • Staff knowledge and training in the area of wound care • Available wound care information resources • Wound care referral patterns and other wound care practices/procedures/documentation • Stock carried and sold • Customer satisfaction with the service and reports of outcome (namely, wound healing) The actual data to be collected was decided as a result of the expert panel phase and is described in 5.2.2. The performance of the pilot indicators were to be examined for: • Feasibility (able to be collected at a cost reasonable to expected value and can be processed

in an appropriate time frame (Audit Commission 2000)) – views of participants and pilot pharmacies, and estimated costs were to be considered. Surveys or interviews were to be used to capture the experiences of participants in the project.

• Reliability and practicality (that the indicator is measurable, valid and reliable and timely) – some audit and retest methodologies were to be included.

• Generalisability to the wider pharmacy population and relevance to the continuous improvement process (the indicator should suggest actions that may be anticipated and feasible and that are plausible in their application (Audit Commission 2000)).

Cost effectiveness of the indicator development methodology was to examine whether the indicators enabled differentiation of service quality at a reasonable cost to: • Pharmacies - From the view point of community pharmacists, in particular, indicators

should be technically efficient. Pharmacies were to be interviewed about their experiences in the trial and cost estimates made for collecting the indicators. Satisfaction with the process was to be assessed through surveys of a sample of customers participating in any indicator surveys.

• The indicator developers – the views of the expert panel were to be sought as to the benefits and costs of the process. The actual costs of the process and other costs that might arise with national implementation (i.e. need for a central data recording and analysis mechanism) would be considered.

The cost effectiveness of using indicators of wound care service quality was to be assessed using a decision analytic model to show long term impact of reduced morbidity associated with poor wound management. Such an analysis would require data on the prevalence of complications associated with poor wound management, e.g. hospitalisation, but data on which to base the probabilities and cost estimates for a decision analytic model were found to be limited. So in retrospect, a decision analytic model of cost-effectiveness was not feasible without at least conducting a reasonable clinical audit to collect this type of information.

7

4. PHASE 1 - ESTABLISH EXPERT PANEL 4.1 METHODS A stakeholder panel of experts was established in phase 1. Some difficulty was experienced in identifying and contacting suitable representatives. To find community pharmacy representatives, the Queensland branches of the Pharmacy Guild of Australia (PGA) and the Pharmaceutical Society of Australia (PSA) were contacted. The consumer representatives were identified by contacts within the Queensland office of Diabetes Australia, and by following a number of leads from various consumer bodies (Consumer Health Forum and the participants list for the 2001 “Improving health services through consumer participation” Conference (leading to the Brisbane Consumers Association)). Three General practitioner (GP) organisations (Queensland Divisions of General Practice (QDGP), Australian Medical Association (Qld) (AMAQ) and Royal Australian College of General Practitioners (RACGP)) were contacted seeking a GP representative. The pharmacist wound care expert identified the wound care medical specialist. A local community nursing service was approached to nominate a wound care specialist nurse for the panel, while the PSA representative identified a pharmacy assistant representative. Podiatrists were felt by one of the investigators (GD) to be the allied health professionals with the greatest involvement in wound care. The national podiatry organisation, the Australasian Podiatry Council, was contacted and asked to nominate a representative. The Medical Industry Association of Australia (MIAA) Wound Care group was contacted and asked to nominate a representative. The Information Technology (IT) manager of the PGA National Secretariat was contacted in an effort to find a representative for the panel who was familiar with the IT environment in community pharmacy and likely future developments in this area.

4.2 RESULTS The expert panel members cover all the stakeholder groups included in the original study proposal namely, consumer and patient support group representatives, community pharmacists (one Pharmacy Guild and one Pharmaceutical Society of Australia (PSA) representative) and pharmacy assistants, one allied health professional (podiatrist), one GP, one community nurse representative, one medical wound care expert, one pharmacy wound care expert, one industry representative and one pharmacy IT expert. Panel members were paid for their time involvement with the study with total payments of $7,800. Payment to individuals were on a sliding scale to cover the opportunity costs of their time – payment ranged from $400 to $1500. Travel costs were met by the study. Luck played a part in identifying a GP representative for the panel (contact through GP organisations was not successful). Two of the study investigators (JS and SC) attended and presented a poster at the Fourth Australian Wound Management Association Conference in Adelaide in March 2002. At this conference, a Queensland-based GP with an interest in wound care agreed to join the panel. The investigators also gave a short presentation to a meeting of MIAA at the conference, and subsequently, MIAA nominated a representative for the panel. After the date for the first expert panel meeting was set, a scheduling conflict required a change to the nominated Pharmacy Guild representative.

8

At the second expert panel meeting, some representatives had changed, as indicated by the two names as representatives for the industry and Pharmacy Guild representatives shown in Table 4.1.

Table 4.1 Members of the Expert Panel and their affiliations

Mr Mark Anderson & Ms Tania Parisi

State Manager, Healthcare Division, Smith & Nephew, representing MIAA (Medical Industry Association of Australia Wound Care group)

Mr Matthew Cichero Podiatrist Ms Dianne Cunningham Wound care Specialist Nurse, Bluecare, Mt Gravatt Dr Harry Gibbs Associate Professor of Medicine & Director,

Vascular Medicine Department Princess Alexandra Hospital

Ms Kathy Kendall Consumer representative Mr Pete Marcus Manager IT Programs, National Secretariat,

The Pharmacy Guild of Australia Mr Bob McDowell & Ms Michelle Bou-Samra

Community pharmacist, Pharmacy Guild of Australia (Qld Branch) representative

Ms Sue Scott Community & hospital pharmacist, Pharmaceutical Society of Australia (Qld Branch) representative

Ms Barbara Sponza Consumer, Diabetes Australia (Queensland) Mr Geoff Sussman Wound care pharmacist, Director, Wound Education and Research

Group, Monash University Ms Sandy Wainwright Pharmacy Assistant representative Dr Stephen Yelland General Practitioner, Gold Coast

9

5. PHASE 2 – DEVELOPMENT OF POTENTIAL QUALITY INDICATORS

5.1 METHODS

5.1.1 FIRST EXPERT PANEL MEETING

The first face-to-face meeting of the expert panel was held at the Princess Alexandra Hospital on 17 April 2002. Prior to the expert panel meeting, An extensive literature search was conducted using bibliographic database searches (Medline, CINAHL, IPA, Australian Medical Index, ABI-Inform) citation searches and a search of the University of Queensland Library Catalogue for texts relating to quality in health care, health care service indicator development and benchmarking in general. No literature was found identifying pharmacy specific wound care indicators. The agenda for the expert panel meeting was to define the nature of community pharmacy service then to brainstorm a series of possible indicators of service quality to cover the structure, process and outcomes of the service (see Appendix A for Agenda and meeting materials). The expert panel members were advised of possible indicators as mentioned in the proposal and in the literature as examples, but a detailed list was not presented to the panel to avoid unduly influencing the views of the panel members and so allowing issues important to each stakeholder to emerge. To facilitate the process, literature about health service indicator development issues and principles was presented to the panel (this information is summarised in 1.2) including an article describing a process used to develop indicators in another health care setting (Shekelle, MacLean et al. 2001). Aspects of acute care and community nursing wound care service quality measurement were also located in the literature and were considered by the panel. Due to the lively discussion in the meeting and the variable nature of “wound care service” offered by community pharmacies, the panel concentrated efforts on defining and describing the nature of the service. Possible indicators were discussed briefly. The expert consultation was conducted using a Delphi technique modified to allow communication between participants to occur both face to face and by electronic correspondence (email). After the initial meeting, details were circulated and feedback was sought. Feedback from individual panel members was combined and circulated to the whole panel for further comment/feedback to reach a consensus. This process was effective and a planned teleconference was not felt to be required by panel members.

5.1.2 DEVELOPMENT OF WOUND CARE SERVICE BEST PRACTICE MODEL

Subsequently, 2 of the investigators developed a flowchart of the service, identified ‘needs’ for quality service delivery and potential indicators related to these The notes of the meeting (a working document in lieu of minutes - see Appendix A) and work arising from the meeting were disseminated to panel members, the other investigators and 3 other pharmacists who expressed interest. Feedback received was incorporated into a draft proposal for the pilot study.

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5.1.3 DEVELOPMENT OF PILOT STUDY PROTOCOL

Panel members were sent the draft proposal for further review. Comments from the panel were considered in preparing the final protocol. A planned teleconference to discuss the materials was not held because of the difficulty in finding a mutually suitable time in the short time frame and because circulated email discussion was considered to be adequate by panel members.

5.2 RESULTS

5.2.1 COMMUNITY PHARMACY WOUND CARE SERVICE BEST PRACTICE MODEL

The expert panel discussed the role of community pharmacy in providing wound care. The role or the scope of the service was seen differently by different stakeholders. Consumers and pharmacists saw the pharmacy as a primary care provider while medical practitioners and other health professionals who considered themselves to have wound care expertise considered the pharmacy to have a secondary care provider role, mostly associated with appropriate product supply. In either role, the community pharmacy service must support optimal wound healing, whether the pharmacy is the primary care provider (e g. for customers seeking treatment for acute cuts or grazes) or secondary care provider (where customers attend other health professionals for primary wound care for conditions such as foot ulcers). The key care steps in optimal wound healing were defined by the panel as (1) History taking and ‘diagnosis’ of the wound, (2) Addressing of aetiologic or contributing factors, (3) Providing local wound management (often as a dressing product) and (4) Monitoring and following up of the wound. As an outcome of Phase 1, a detailed flow diagram of ‘best practice’ was developed to incorporate all of these steps while allowing customer self-selection and identifying the need for referral to other health professionals or services e.g. wound clinics or hospitals, for wound care. The flow diagram is shown in three figures (Figure 5.1 to Figure 5.3).

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Customer enters pharmacy

Seeksadviceinitially

Select productfrom display

No

Pharmacy assistantresponds

Yes

Customer presentsfor purchase

Seeksconfirmation

of choice

Pharmacy assistantexplains need to confirm

product selected

No

Yes

Preliminary datacollection by

assistant

Customer firstvisit for care of

this wound

Reviewrequested bypharmacist

No

Satisfactorywound

progress

No

Refer topharm-acist

NoYesDurationof wound

Refer topharm-acist

How woundstartedknown?

<=4wks

Refer topharm-acist >4wks

Wish to seepharmacist

Yes

Refer topharm-acist

Yes

Treatmentso far

No

Infection riskincl tetanus

LowRefer topharm-acist

Unc

erta

in

Known,Chronic

Known, acute

High risk

Supply previoustreatmentproduct

Effe

ctiv

e

Recommendappropriatetreatment

Ineffective orno previoustreatment

Refer topharm-acist

Yes




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

Yes

Flow diagram symbol key:

Figure 5.1 Flow diagram of wound care service in community pharmacy – Part 1, interactions with a pharmacy assistant

Decision Start/end Action or process Connector

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Refer topharm-acist

Assistant reportsdata collected sofar to pharmacist

Pharmacist completes datacollection confirming data

collected fo far


this wound

No Satisfactorywound

progress

Progressnot OK

No

Durationof wound

Origin ofwound

<=4wks

>4wks

Yes

Take relevant drug andmedical history

Known,Chronic oruncertain Known, acute

Continuetreatment as

planned

Furtherpharmacy follow

up required

Episodecomplete

No

Arrangefollowup

Yes

Ascertainlocation of wound

Other HealthProfs

involved?

Need toconsult otherhealth profs

Risk factors fromdrug/medical

history

Refer toappropriatehealth prof

No

Prepare localtreatment plan

until appointment

Yes

Yes

Complete all history steps above and:- signs & symptoms- tests done/results- social/environmental history- observe wound if practical- customer understanding of wound

No


up required

Arrangefollowup

Yes

Transfer careto OHP

No

Recommendtreatment plan andcounsel on product

use

No


up required

Arrangefollowup

Transfer careto OHP

No



until appointment

Yes

Discuss/arrangemonitoring

Episodecomplete

Consult withhealth prof

YesWhat doesfeedbacksuggest

Prepare treatment plan

Refer

Refer topharm-acist



collected fo far


this wound


progress

Progressnot OK

No

Durationof wound

Origin ofwound

<=4wks

>4wks

Yes




planned


up required

Episodecomplete

No

Arrangefollowup

Yes


Other HealthProfs

involved?



history


No


until appointment

Yes

Yes


No


up required

Arrangefollowup

Yes

Transfer careto OHP

No


use

No


up required

Refer topharm-acist



collected fo far


this wound


progress

Progressnot OK

No

Durationof wound

Origin ofwound

<=4wks

>4wks

Yes




planned


up required

Episodecomplete

No

Arrangefollowup

Yes


Other HealthProfs

involved?



history


No


until appointment

Yes

Yes


No


up required

Arrangefollowup

Yes

Transfer careto OHP

No


use

No


up required

Arrangefollowup

Transfer careto OHP

No



until appointment

Yes


Episodecomplete




Refer

Figure 5.2 Flow diagram of wound care service in community pharmacy – Part 2, interactions with a pharmacist where first presentation of a wound or a subsequent presentation where wound healing is progressing well

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Progressnot OK

Significant/relevantchanges

Discuss plan &modify to suit

customer needs

New treatmentplan

Consultother Health

Profs?

Review history &plan

Any changes oradditions to

original history

Appropriateproduct

use/followingplan?

Yes

No No

Yes

Yes

No

No

What doesfeedbacksuggestP

repa

retre

atm

ent

plan

Yes

Transfer careto OHP



until appointment

Refer

Proceed with treatment plan:- provide appropriate productCounselling on:- product use- tissue integrity (of surrounding skin)- wound cleansing


up required

Arrangefollowup

No


Episodecomplete

Yes

Progressnot OK



customer needs

New treatmentplan

Consultother Health

Profs?



original history

Appropriateproduct

use/followingplan?

Yes

No No

Yes

Yes

No

No


repa

retre

atm

ent

plan

Yes

Transfer careto OHP



until appointment

Refer



up required

Arrangefollowup

No


Episodecomplete

Yes

Figure 5.3 Flow diagram of wound care service in community pharmacy – Part 3, interactions with a pharmacist where a subsequent presentation where wound healing is not progressing well

The details for the steps in each box, such as "Preliminary data collection" and “Recommend appropriate treatment” would need to be defined for each site but guidelines could be developed to support these actions. For “Preliminary data collection”, many of the details needed to gather information about wound features that would inform either dressing selection or referral are shown in subsequent diamonds in the flow chart. Defining “Recommend appropriate treatment” was considered to be outside the scope of the project by the panel. The panel indicated that the “Recommend appropriate treatment” could lead into a clinical pathways flowchart to aid in treatment or clinical decision making.

14

Based on a review of the flow diagram, it was felt that 2 models of practice would best describe community pharmacy wound care services – standard service and an advanced (or niche) service, and within each of these, there could be low and high service quality. The following service elements, common to both practice models, were considered to be necessary to support optimal wound healing. 1. Stock/supply chain (making sure appropriate stock is on hand when required and the

products are displayed to facilitate best wound care, for example with customer information leaflets)

2. Identify customer requiring wound care service 3. Information collection to guide product selection or determine the need for referral or other

services 4. Decide whether referral is required and make referral 5. Supply appropriate products and advice (on their use and wound healing/care/prevention as

appropriate) 6. Data capture and documentation of the service (keeping appropriate records) 7. Follow-up of wound healing progress 8. Quality assurance processes (e.g. conduct patient surveys, aggregate and analyse data

captured) In an advanced service, these elements might be performed/provided at a more intensive level, with the addition of other possible service elements (e.g. changing dressings).

5.2.2 DATA COLLECTION TOOLS DEVELOPED FOR PILOT STUDY

The best practice flow chart and results of the first expert panel meeting were used as a basis for the development of the data collection tools to facilitate the collection of data related to possible indicators. The data items (and hence potential indicators) included in the tools were intended to address the structure, process and impact aspects of any wound care service. To reduce the response burden on the pharmacists and to provide additional validation of some of the elements of pharmacist-reported data (e.g. stock range carried), it was decided that certain observational data collection (objective information such as the linear metres of wound care shelving) and a customer telephone survey would be carried out by the research team, although the original intention was for pharmacies to collect all indicator data. The audit visit also provided an opportunity for quality assessment independent of pharmacy staff views. The data collection tools can be found in Appendix B – items were assessed for content validity against the best practice model. Each tool may include or yield a number of potential indicators such as staff training and knowledge, business size, various wound care practices and policies, staffing levels, wound care section layout, stock holdings and sales in various dressing categories and other measures included as validation e.g., stock holdings (sought in two instruments). To improve reliability of data collection, a comprehensive instruction sheet, including a summary diagram, was provided to the pharmacies to describe the nature of data to be collected and identifying those data items for which responsibility for collection could be delegated to other staff. The data requested from the pharmacies included: • A Wound Care Service Profile in which a range of practice characteristics were recorded • Current stock holdings • Retrospective, longitudinal data on sales or purchases of wound care products. Since the

expert panel suggested that not all pharmacy point-of-sales and dispensing computer

15

systems would be able to generate a report of such data, pharmacies were advised that purchases data (that could be obtained from wholesalers) could be used as a proxy

• A log of the type of wound dealt with by the pharmacy for a specified time period. This log does not identify customers but records wound presentations according to simple wound characteristics and summarises service elements such as the product/s provided, pharmacist consultation and referral to other health professionals.

• Prospective sales and number of transaction in and 8 week period as validation for completeness of the log and customer survey recruitment.

• Pharmacist and pharmacy assistant quizzes on wound care knowledge A customer log was felt to be necessary because there is limited information available on the type of wound seen in community pharmacies and the spectrum of wounds seen will depend in part on the character of the pharmacy and the community it serves. To assess the appropriateness of products sold, the nature of the wound must be known. The data collection tools were used to collect data on the following potential indicators (Source of data R=reported by proprietor; A=recorded at independent audit; L=recorded by staff on the customer log; Q=quiz): Rural versus metropolitan (A) Physical size of pharmacy (A) Opening hours (R) No. prescriptions filled/week (R) No. pharmacists employed (R) No. EFT Pharmacists (R) & No. EFT Pharmacy assistants (R) In banner group (A); QCPP accreditation (R) Providing dressings to other organisations (R) Nature of signage for the wound care area (A) Linear metres of shelving for wound care dressings (A) and percentage of dressing shelves for wound

care (not first aid) products (A) and total linear metres of dressing shelving (A) Extent of use of manufacturers’ displays (A) Attention to merchandising other than the use of manufacturers’ displays (A) Availability of written information on wound care for customers to take away (R) Wound care referrals by pharmacy to other health professionals (R & L) Wound care referral to pharmacy from other health professionals (R) Wound history taking (R); Maintenance of patient wound care records (R); Monitoring and follow-up

of wound healing (R) Existence of wound care policies/procedures whether written or unwritten (R) Extent of pharmacy assistant influence on purchase (L) Frequency of pharmacist consultation in a wound care service episode (L) No. pharmacy assistants with wound care training (R) Proportion of opening hours a wound care trained assistant was on duty (R) Pharmacy assistant & pharmacist knowledge scores (Q) Presence of product selection information resources (R); Presence of wound assessment information

resources (R) Percentage of patients seeking wound care for various wound types (R & L) Overall stock range and stock level (A) Stock range and level of more specialised dressings (A) Percentage of dressings sold not passive or first aid dressings, tapes or bandages (L) Percentage of turnover from wound care (R)

5.2.3 PILOT STUDY PROTOCOL REVISION

The output of Phases 1 and 2 was an application for ethical approval for a pilot study. This application was approved by the PA Research Ethics Committee (see attached approval letters,

16

Appendix D). Endorsement of ethical approval was also granted by ethics committees from the two universities involved with the study. The research plan for the pilot phase was further developed from the proposal submitted to the Guild. The following details were incorporated into the pilot research plan: • Use of an independent mystery shopper to provide an external assessment of service quality,

against which pharmacy reports and consumer surveys were to be compared. The possible use of independent industry validation data was also explored but concerns over confidentiality, the consistency and quality of the industry held data and on its availability for all pilot sites precluded the use of this data source.

• An increase in the number of pilot pharmacies to better sample the four theoretical levels of service quality defined as part of the expert panel discussions (see Figure 5.4). It was anticipated that service level and service quality were likely to be continuous, however, pharmacies were to be sampled to test whether indicators could differentiate between low and high quality in a basic wound care service and low and high quality in an advanced service.

• Use of a telephone survey of consumers. Pharmacies would enroll consumers but the study team would conduct the interviews. The survey was largely exploratory and used open ended questions. Each participating pharmacy was asked to recruit a minimum of 10 consecutive consumers of wound care services (where the customer was seeking wound care for an individual with a current wound – customers purchasing wound care e.g. first aid ‘just in case’ for some future wound were to be excluded). There were no pre-existing measures on which to base any power calculation but a sample of 10 to 15 consumers was chosen to balance the recruitment burden and survey costs against the qualitative information provided. The turnover of wound care products can be low so that even a sample of 10 consumers per pharmacy may have taken several weeks to recruit.

Basic

Advanced

Service Level

Service Quality

Low High

Basic

Advanced

Service Level

Service Quality

Low High

5 5

5 5

Figure 5.4 Theoretical sampling framework

17

6. PHASE 3 – PILOT STUDY METHODS 6.1 RECRUITMENT This pilot study involved the recruitment of a small number of community pharmacies of varying wound care service quality. A purposive, convenience sample of pharmacies were selected to reflect the characteristics of pharmacies in terms of practice types (medical centre, shopping centre and strip pharmacy) and location (city versus country). Previous unpublished work by the Wound Education and Research Group (WERG) found that turnover was did not influence wound care practice. Victoria was chosen as the location for the pilot because the distances to travel to reach a rural locality were shorter than in south east Queensland and because several pharmacies were located in Victoria who were known to provide a very high quality service any of whom would be a suitable benchmark site (as industry leader). Pharmacies recruited into the pilot study were to cover a representative range of wound care service provision, from poorly provided basic service to very high quality, advanced service. Preliminary observation 35 sites identified from the telephone book as being in travel corridors to minimise travel costs (the reason for conducting the trial in Victoria) suggested that the majority of community pharmacies provided a low to intermediate quality service. Each of these sites was briefly visited by an investigator who located the wound care section of the pharmacy and gained an impression of the size, layout and stock (estimated relative proportion of wound care versus first aid stock). A global service quality rating was assigned based on product range and display, as could be seen from walking into the pharmacy. This subjective rating (reached through agreement between two investigators) had 7 levels - low quality rating in a basic service, low to intermediate service quality, intermediate, intermediate to high, high and very high quality basic service, and advanced. All of these sites bar 3 (see 7.1) where approached to participate in the pilot. Since an industry leader should be included in any benchmarking exercise, several of the potentially more advanced service providers who were known to the WERG were approached (three included as likely higher-end service providers and one because of a high turnover of wound care products due to a contract with a district nursing service for wound care product supply). Originally, a minimum sample size of 15 was felt to be sufficient to demonstrate between pharmacy differences while allowing for adjustment of practice type and limiting the costs of the pilot phase, although for greater generalisability, the target sample size had been increased to 20 (5.2.3). For the indicator development methodology to be viable, costs must be constrained. The first step in selecting the pilot sample was to identify possible pharmacies in Victoria that might be representative of the range of wound care services provided by visiting pharmacies and observing their wound care display. Screened sites, except 2 atypical pharmacies, were telephoned, an explanation of the study was given and pharmacies were invited to participate in the pilot study. On their verbal agreement, pharmacy information sheets and consent forms were sent to the pharmacy for completion.

6.1.1 PILOT STUDY START-UP

Once the pharmacies had consented to participate, a kit of the documentation to be completed by the pharmacy and a detailed instruction sheet was sent or delivered in person by an

18

investigator. At this time, further explanation about the project and exactly what was required for data collection (including what could be delegated) was given to a key person in the pharmacy. In the majority of pharmacies, this person was a pharmacist but in 3 of the sites, the key person was a pharmacy assistant.

6.2 QUALITY INDICATOR DATA COLLECTION Data for the assessment of potential quality indicators was collected by both pharmacies and the research team. Observation and disguised/mystery shopping was used as an independent measure of service quality ‘in fact’. A customer survey was used to attempt to assess functional or perceived quality. Multiple sources of data were collected for each pharmacy to be triangulated against independent measures of service quality. Pharmacies trialling indicators were paid $300 to offset some of the data collection costs. A detailed instruction sheet (see Appendix B) explaining each step of the pilot and the actions required of the pharmacy with a timeline was provided to the sites. This was also presented as a diagram (Figure 6.1). The activities in the boxes with the solid borders were to be undertaken by the pharmacy. The mystery shop, audit and customer telephone survey were to be undertaken by the research team. These latter activities did not appear on the version of the diagram provided to the sites as a visual reminder of the study protocol.

Day 0

Day 1

Timeline

Day 14

Day 55

Day 17

Receive documents kit Pharmacists & pharmacy assistants to read Important Instructions

Complete:• Wound Care Service Profile• Current Wound Care Stock

Holdings• Wound Care Sales or

Purchases History

Start Customer log

recording

Start recruiting customers for survey

For each customer recruited, the same day, fax consent forms to VCP on 03 9903 9629

End recruitment after 8 weeks or if 15 customers recruited.Note date of last recruitment

After 2 weeks - Return forms and completed customer log

Receive pharmacist and pharmacy assistant quizzes

Distribute quizzes & return completed quizzes within 10 days

• Report wound care sales over 8 week period• Report on No. of wound care or first aid transactions

over time taken to recruit customers

Receive/respond to “Trial experience” survey

Day 27

Audit visit

Mystery shop

Telephone survey 1 & 2

Figure 6.1 Pilot study data collection activities and timeline The pharmacies were asked to collect information on items related to the structure, process and impact aspects of any wound care service. The views and perceptions of the owner or manager were sought as part of the ‘Wound Care Service Profile’. Sales data and stock holdings data were collected by wound dressing category. A glossary was provided to the sites to help them with the classification of the various wound care products into the appropriate category to ensure consistency.

19

After the initial pack of materials were delivered, a set of quiz forms were sent or delivered to the pharmacy for completion by pharmacists and pharmacy assistants. A reply paid envelope was included to allow individual respondents to reply confidentially. A log of wound care customers was maintained by the pharmacies. In most sites, this A4 sheet was kept near the cash register, and was completed with each transaction. During the data collection phase, the pharmacies were contacted repeatedly by telephone or by a face-to-face visit. Problems sites were experiencing with data collection were addressed and questions were answered.

6.2.1 CUSTOMER RECRUITMENT AND SURVEY

Informed consent to participate in a telephone feedback/follow-up survey was sought from consumers of wound care services by the pharmacies. Consent documents are shown in Appendix B. The pharmacy staff were asked to invite consecutive customers purchasing wound care products from the pharmacy (excluding those purchasing first aid ‘just in case’ and those purchasing wound care products on behalf of another) to participate in a telephone survey (although as indicated in the post-pilot interview, this was generally not done, see 7.3). A written information sheet was provided to the consumer together with 2 paper, disposable rulers, and the consumer was asked to complete a consent form (see Appendix B). The contact details on the consent form were then faxed to the research team. A research assistant then attempted to telephone consenting consumers and complete a semi structured interview (see Appendix B for the survey form and procedure). In some cases, up to five many attempts were made. Where wound healing was likely to be prolonged, the interviewer was to ask the customer to record the dimensions of the wound at the next dressing change and seek permission to contact the customer again approximately 2 weeks later to ask about wound size and any problems using the dressings. The pharmacy was asked to report the total number of wound care transactions made during the time it took to recruit the customers to be surveyed to determine the completeness of the sample.

6.2.2 INDEPENDENT AUDIT

An independent audit of each site was undertaken by a member of the research team who has expertise in wound care and experience working in community pharmacies (GD). Each site was visited and the researcher advised the pharmacist and staff that an audit of the wound care section was to be conducted. The researcher then made the observations called for by the data collection form including a measurement of linear shelf space assigned to wound care, and a sketch of the pharmacy layout in relation to the wound care section. This sketch was subsequently not used as a data source because the issues of concern e.g. whether the pharmacist could see the section from the dispensary, were also included in the audit form.

6.2.3 MYSTERY SHOPPER VISITS

A protocol and scenario were prepared for the mystery shopper program. The scenario was a direct product request where the shopper, an adult woman, entered the store, looked for the wound care section. When approached by a staff member, the shopper asked for Melolin and then responded to any information seeking questions asked by the staff member. If the shopper

20

was not approached by a staff member, the shopper found the product and took it to the counter, again giving the staff an opportunity to interact with the customer about wound care. At the end of the episode, the requested wound care product was purchased. On leaving the pharmacy, the shopper completed the data recording form. The procedure and data recording forms are shown in Appendix B. To validate the data collection method, which relied on the recollection of the mystery shopper, data recording sheets were completed independently by 2 visitors, both present for the same interaction, at 7 sites (costs constrained this validation at all sites). Inter-rater reliability was then examined.

6.2.3.1 Scoring the mystery shopper episodes

A scoring scheme was developed for the episode that did not include how long it took to be served and when the service occurred (at the counter versus on the shop floor) since the data collection was a single shopping episode and so did not allow for variations in how busy the pharmacy staff or the pharmacist were at the time of the visit. There were also variations in the interpretation of the question on time taken before assistance was provided. Since few of the ‘best practice’ steps (first page of the flow diagram) were followed by any of the site, the key service issues to be scored were whether or not information about the wound was sought, whether the pharmacist was consulted or the customer was referred to the pharmacist and whether advice was given to the customer (an objective measure). The scoring scheme for the mystery shopper recording sheets was: 1. The pharmacy kept the product or equivalent = 1 point. Product or equivalent not available

= 0 points 2. No assistance at all (just paid for the self-selected product and left) = 0 points. Any help at

all = 1 point 3. Someone (either the assistant or the pharmacist) sought more information from the customer

= 1 point. No information sought = 0 points 4. For each piece of information that might be used to assess the wound and associated risk

factors in order to check product selection = 1 point for each information category (5 possible categories)

5. Any referral to or consultation with the pharmacist = 1 point. No referral or consultation = 0 points

6. Any advice on wound care or product use given = 1 point. No advice given = 0 points 7. 1 point for each separate piece of advice given with relevance to wound healing or product

use., e.g. if gave 2 pieces of information about how to best use the product, then score 2 points, up to a maximum of 6 points.

Thus the range for the score was 0-16. In developing the mystery shopper scenario, we had intended to rate the appropriateness or importance of the advice given (by awarding bonus points), but so little advice was given that such rating was not considered feasible. The mystery shoppers were also asked to rank the shopping episode globally in terms of service quality, considering assistance, advice and the tangible aspects of the service such as the display (a subjective measure).

21

Figure 6.2 First page of best practice flow diagram showing interaction between pharmacy assistant and customer (adapted from Figure 5.1)

6.2.4 POST-TRIAL INTERVIEWS WITH PHARMACIES

After or close to the end of the data collection phase, semi-structured interviews were conducted with the key contacts/people involved with the pilot at each site. The interview was conducted face-to-face at 7 sites. Two of these sites had not mad much progress and so the interview was postponed. These sites plus the remainder were interviewed by telephone. Interviews took between 5 and 40 minutes. At the start of the interview, pilot participants were advised that the researchers were seeking feedback about their experiences with the pilot study and associated data collection including what was good and bad about the pilot, what data items were feasible and useful, and their views about participating in research. The following questions were used as prompts to elicit information that was not spontaneously reported by the respondent: 1. Was the purpose of the pilot study clear to you? The aim of the pilot was to develop a self-

audit package for pharmacies to assess their wound care services in a way that identified areas for possible improvement.

2. Were the materials easy to use? How could they be improved? 3. What was the most time-consuming data to collect? 4. What was the most difficult indicator to compile? 5. With the customer survey, what do you think were the reasons why customers were

unwilling to take part?




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

YesCustomer firstvisit for care of

this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

Yes

22

6. Which indicators, if any, do you see as useful and feasible in practice? For example, would you repeat any of them in next year for your own practice purposes?

7. Did you see any benefits in measuring the kind of data we asked you to? If Yes, what type of benefits and did the benefits outweigh the cost to you? During data collection, did you think about how your own practice was going?

8. Are there any changes to Point-of-sales or other electronic systems that could make the routine collection of this kind of data easier?

9. This pilot project is really the first step in the CQI (continuous quality improvement) process; if the pilot results identified possible areas for practice improvement, would you act on this?

10. Have you gained a better understanding of what it takes to do research from your participation in the project? Was the research aspect new to you? Did you get anything out of participating in research? What training or resources would have made the research process easier? In general, how do you feel about continuing with different research projects?

11. Would you do this research again? If not, why not? Notes were kept from each interview and common themes were extracted.

6.3 EVALUATION OF POTENTIAL QUALITY INDICATORS

6.3.1 DATA PREPARATION

Data were entered into a purpose designed Microsoft Access database, except for the customer telephone surveys that were examined in hard copy (since there were so few). The data were cleaned to deal with anomalies (e.g. percentages not adding to 100) and missing values. Data cleaning involved a check of the entered data against hard copy, to confirm that missing data was actually missing and not a data entry error. Other apparent data anomalies were checked in the same way. Some data items asked respondents to list percentages of wound clients across exhaustive categories. In some cases, numbers were written for all categories but the total was not 100%. In these cases, the values were adjusted proportionally so that the denominator was 100. Where the total of percentages was less that 100 and some categories were left blank, the percentages given were used and uncompleted categories set as missing. Independent quality scores (independent of the pharmacy staff) and aggregated variables for stock on hand and sales/purchases data were calculated. Data items where there were multiple responses per pharmacy i.e. customer log, quizzes were aggregated to provide a ‘per pharmacy’ score or response (aggregation is described in the following sections). All other data items had a more straightforward coding. Interval and continuous items were used as recorded (items on the 100 mm visual analogue scales were measured from the left-hand end) or after a simple calculation e.g. the percentage of total dressings shelving used for wound care products was calculated by dividing the linear metres of wound care shelving by the total linear metres of dressing shelves (multiplied by 100) or the number of wound care policies that were written calculated as a percentage of 11 possible policy types. Estimated pharmacist hours/week was calculated by summing opening hours and the number of hours per week where more that one pharmacist was on duty. This estimate was divided by the number of Effective full-time (EFT) pharmacists to give the hours/week/EFT pharmacist. Categorical items were coded such that if the item was a yes/no item, having the attribute was coded as 1 and not having the attribute as zero or if the item was ordinal, the lowest category was coded as 1 and the highest category coded as the high value.

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6.3.1.1 Audit data

Only the data on stock holdings required any analysis to allow aggregation per site. For each site, a “stock range” score was calculated. For each dressing type category, the number of bands stocked (where none=1, one brand=2, more than one brand=3) was multiplied by the number of sizes stocked (none=0, 1 size=1 and more than 1 size = 2) giving a score for each dressing type of between 0-6. The scores for all dressing types were summed to give a stock range score. A total stock score was also calculated by multiplying the stock range score for each dressing type by the number of individual units stocked category (where 1=<5 units, 2=5-10 units and 3=>10 units). Again, the scores were summed for each dressing type.

6.3.1.2 Stock and sales data

Stock holdings data were coded using the same scheme as the audit stock data, so that audit and stock holdings as reported by the pharmacy could be compared. The number of different products stocked in each category (multiple sizes of the one product were only counted once but different types of the same product e.g. Kaltostat sheets and Kaltostat rope, were counted separately) were counted for each site, to examine the most frequently stocked items. The actual number of individual dressings stocked was only summed within each dressing category for the sites also providing the sales or purchase history data required. The sales or purchase history data collection form sought the percentage of total wound care sales for the number of individual units sold (not the dollar value) in each dressing category. For most sites, the data provided was not a proportion and so proportions of total sales were calculated. Since stock holdings quantities for first aid products were difficult to aggregate, in order to compare stock holdings with sales, the proportion of sales in the various categories was recalculated to exclude this product type.

6.3.1.3 Quizzes

The quizzes were scored according to an answer sheet so that Question 1 was a maximum of 6 marks, Question 2 a maximum of 12 marks and Question 3 (pharmacists only) a maximum of 14 marks. Since the pharmacy assistant and pharmacist quizzes had questions 1 and 2 in common, scores for these two questions were summed. For the pharmacist quiz, a total score out of 32 was also calculated. An average score per pharmacy for each quiz type was the calculated.

6.3.1.4 Customer log

The customer log required data cleaning because some sites recorded more than 2 weeks of transactions while others included non-wound care transactions (e.g. sports-related). The transactions within a 2 week period and transactions for sports, sprains and strains and non-wound care purposes were identified. Subsequent analysis focused on the 2 week period and excluded sports, sprains and strains and non-wound care transactions, although in some cases, these results were included for completeness. The customer log also asked the staff member to indicate whether they had influenced a customer’s product choice or actually changed the choice. While the difference between these data items was explained in the pilot materials, in some transactions, both boxes were ticked. Where both boxes were ticked, if there was only 1 product supplied and there were no other comments to indicate a change in choice rather than guidance in product selection, then the transaction recoded as “influence” rather than “changed” customer’s choice. Were more than 1 product was supplied, both “influence” and “changed” customer’s choice were retained.

24

The appropriateness of the products supplied at each transaction was rated independently by 2 wound care experts (one investigator and 1 panel member). A rating scheme was used to rate each customer episode when considering the wound information recorded and the products supplied as this related to potential effects of the product/s on wound healing (where 1 rating was assigned per episode). The rating categories were as follows: -1 Potential to delay healing 0 No potential to help healing 1 Limited potential to help healing 2 Potentially appropriate to help healing 3 Potentially very appropriate to help healing 8 Not enough information provided/unsure 9 Not applicable (e.g. scar reduction) For products with a future use, raters were asked to imagine the types of wounds customers are likely to use these products but to exclude customers with sprains/strains/sports related needs. Inter-rater reliability was examined for the appropriateness rating of the customer log. Rating scores were averaged between the two raters for each site, with the rating for a single rater was substituted for any product rated by only 1 rater. These average ratings scores were aggregated per site as an average per product/site and the aggregate score was used in subsequent analyses.

6.3.2 INDEPENDENT QUALITY SCORES

To establish a more robust independent (of the pharmacy staff) quality measure, the overall quality score form the audit visit was combined with both the mystery shopper score and the mystery shopper rank as follows:

Independent quality score = Audit overall quality + (Mystery shopper rank + score) x100/30 This calculation gave an overall score that potentially ranged from 3.3 to 200, and accounted, to some extent for too much weight being given to poor performance on a single mystery shopper visit. A second quality score was also calculated to incorporate the average appropriateness ratings of products sold in a 2 week period, giving this assessment equal weight with the other components but giving a score out of 100:

Combined quality score = (Independent quality score + (mean of average† appropriateness of products sold/site x 100/3))/3 † average of 2 raters per product

6.3.3 DATA ANALYSIS

Both quantitative and qualitative data were collected and analysed in the pilot study. Quantitative data were aggregated to allow comparison at the pharmacy level. The qualitative data (post-pilot interviews and responses to open-ended questions) were examined for common themes. The data analysis plan was based on the criteria for the performance of indicators (see Chapter 3) and involved: • The development of independent quality measures and checks of correlation and reliability.

These measures were taken from the independent audit and the mystery shopper visits. The appropriateness rating of wound care products sold per the customer log was also considered to be a proxy quality measure.

• The aggregation of data to give potential indicators e.g. calculation of a stock range score

25

• Comparisons of indicators with other indicators e.g. Quiz versus training, stock versus sales, stock versus wound types, stock from audit versus stock from self-report. Potential indicators were compared with other potential indicators as a form of validation and to see whether an indicator was redundant (i.e. strongly related to another indicator).

• Comparison of potential indicators with independent quality measures Since this was a pilot study and the numbers of cases were small, the significance level was set at p<0.05 but relationships with a probability of less than 0.1 were of interest and considered in the interpretation and discussion of findings. Statistical tests (predominantly the non-parametric tests, Mann Whitney U, Kruskall Wallis and Spearman’s correlations) were carried out using SPSS for windows version 11.0.

6.3.4 SECOND EXPERT PANEL MEETING

A second expert panel meeting was held towards the end of the pilot study on 30 June, 2003. At this time, only half of the sites had returned a substantial amount of the data requested. The participants from the first expert panel meeting were contacted however, a number of changes to the panel were required because of a change in the representatives of the Pharmacy Guild and the industry. Panel members were circulated to determine the optimal time for a meeting, where the maximum number of panel members could attend. At the meeting, a summary of findings to date and possible recommendations arising from the project were presented (see Appendix E) and discussion was invited from panel members. Notes of the meeting were taken and added to the presentation images. A number of additional recommendations came out of the meeting. The draft discussion and executive summary of this report was circulated to panel members for comment prior to submission.

6.3.5 FEEDBACK OF RESULTS TO PARTICIPATING SITES

After the data entry, coding, aggregation and analysis included in this report was completed, the summarised benchmarking results were fed back to each site. A report was prepared (see Appendix F) that included the: • The benchmarking data. This section describes each potential indicator showing how

various sites fared. In this section, proprietors would be able to compare the results from their pharmacy with those from other pharmacies, including the benchmark site.

• Independent quality measures - a variety of independent measures (i.e. measures or assessments conducted by independent assessors who not involved with or employed by any individual pharmacy) that allows for comparison between sites as well as general measures of service quality

• A comparison of the potential indicators and the independent quality measures – this assessed the relationships between indicators and independent quality measures

The covering letter indicated that the data in this report comprised steps 1, 2 and 3 of the Plan-Do-Check-Act continuous improvement cycle, and that if the sites acted to improve their wound care service, this would complete the CQI loop. Sites subsequently were telephoned and asked whether they had received the report, whether they had read it, and whether they had found areas for improvement of their wound care service in the report.

26

7. RESULTS OF PHASE 3 – CONDUCTING THE PILOT STUDY

7.1 RECRUITMENT AND STUDY WITHDRAWALS In all 35 pharmacies (15 in rural or provincial areas), were screened to see whether they represented a cross-section of community pharmacy types and wound care service types (including a global assessment of quality based on product range and display). Of these, 9 and 14 were rated as having a low to low-intermediate quality rating in a basic service, 8 as intermediate to intermediate-high and 4 has higher quality basic service (66% low-low-intermediate versus 34% intermediate-very high basic). Thirty-three of the screened sites were approached to participate in the pilot study, in addition to 4 other pharmacies metropolitan sites believed to be higher quality service providers due to their association with WERG. Two pharmacies were not approached because they were atypical of other pharmacies (1 extremely small rural and 1 small Central Business District (CBD) (that stocked only first aid) pharmacy) and one site closed between the screening visit and recruitment (all screened at the lowest level). Seventeen of the pharmacies approached declined to take part in the pilot study, either immediately or after some thought. Most of these pharmacies were supportive of the idea of the pilot study but time and staffing issues were the concern. At one pharmacy, the negative response was very blunt – this site did not participate in research (described as surveys) and were dismissive about clinical roles for pharmacists in community practice and that pharmacy is a supply function. Initially 20 pharmacies agreed to participate, 12 from the city and 8 from rural or provincial areas, however, 6 later withdrew their consent. Of these, 5 were city pharmacies, one of which was a potentially high level service provider, and 4 were banner group pharmacies. Only 2 of the 6 sites with the lowest global service quality rating from the screening visit who were approached agreed to be involved with the study, and only one of these sites completed the trial. Of the 11 screened sites, 5 (45%) of sites completing the pilot were rated as low-low-intermediate in the original screening visit. The location, type and size of the pharmacies (as estimated at the independent audit visit) are shown in Table 7.1. The majority of pharmacies were strip pharmacies with the other site types being shopping centre, medical centre and stand alone. Three of the 14 sites were banner group pharmacies (21%). Twelve pharmacies (86%) were in PhARIA category 1 (5 of which were in or near a regional centre, and so classed in PhARIA category 1)

Table 7.1 Size, type and location of pilot sites (shown by ID number)

Size (m2) Type Metropolitan Rural including regional centre sites Strip M05; M06; M11 R02; R08 <200 Other Strip M01; M04; M08 R01; R04; R07 >200 Other M03 R05; R06

7.1.1 CONTACT WITH SITES DURING PILOT STUDY

Recruitment and retention of study sites, and persuading sites to collect data took a lot more time than was anticipated. Initial telephone contact was made to gain verbal agreement to participate. This was followed by a face-to-face visit by a researcher (GD) to explain materials and pilot requirements. After this visit, repeated telephone calls (in some instances weekly)

27

were made to support and persuade sites to collect data. In some sites, 2 or 3 other visits were made to explain the pilot activities and reiterate study requirements. Staff changes and the absence of key people were two reasons why such repetition was required. In other cases, pharmacies found it difficult to find the time to concentrate on the project, and to just get started (given that the pilot phase coincided with the nationwide recall of Pan Pharmaceuticals products). In general, once a site started the data collection, they had few problems continuing.

7.2 DATA COLLECTED For the purposes of the pilot, some of the audit/benchmarking data was collected by the research team (shown by an asterisk in the ‘tasks completed’ column of Table 7.2). Apart from the customer survey which was partly dependent on recruitment by the pharmacies, these data items were collected for each site. Almost all sites completed the profile form (the proprietor’s perceptions) and the customer log. By the end of the study, one site had returned only the customer log. The pharmacist at the site where the customer log was not completed indicated at end of trial interview that 2-4 wound care/first aid customers were seen each week. No information was collected on the sales of wound care products over the 8 weeks of the pilot (not just the 2 weeks for the customer log) because this information was not readily available as indicated by the relatively poor response for the sales/purchase history data (see also post trial interviews). Poor responses were also seen for customer recruitment and the customer survey (6 could not be contacted or withdrew). The data measures, eight-week sales history and number of transactions were not potential indicator items, but rather, an attempt to determine the completeness of the customer survey recruitment. Since customer recruitment was low and few sites were able to supply these data items, collection of this information was not laboured (the lack of information about specific types of transactions is a study finding in itself). Four sites did not return any pharmacist quizzes and 3 failed to return any staff quizzes.

Table 7.2 Types of data collected for pilot sites

ID Number Tasks completed M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08 TotalAudit visit form* 14 Mystery shopped* 14 Profile form nd 13 Customer log nd 13 Stock holdings nd nd 12 Sales/purchase History nd nd nd nd nd nd nd nd 6 8 week sales Number of transactions

Not collected by any site

Patients recruited 1 1 2 1 3 6 1 15 Patients responding* 0 1 1 1 2 3 1 9 No. pharmacists 4 3 3 1 2 2 2 2 2 3 2 1 2 29 No. assistants 1 4 6 3 3 2 6 5 6 7 5 5 6 59 Quizzes sent 14 Quizzes returned Pharmacist Assistant

4 1

2 7

3 3

1 3

1 1

1 2

1 1

2 4

2 3

nd 3

nd nd

nd nd

nd nd

2 6

19 34

End of trial interview* 14 nd= not done * carried out by the research team

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7.2.1 TIME TAKEN TO COLLECT DATA

As part of an assessment of feasibility, sites were asked to indicate approximately how long it took to complete each data form. In keeping with the reports at post-trial interview, the sales/purchase history data and the stock holdings data was the most time consuming to collect (Table 7.3).

Table 7.3 Length of time to collect each data element

Tasks completed Time taken to complete Audit visit form Median=20minutes, Range 15-30 minutes Mystery shopper Estimated 10 minutes excluding travel time Profile form Median=30 minutes, Range 10-60 minutes Customer log Not collected – estimated to be <1minute/customer Stock holdings Median=60 minutes, Range 20-120 minutes Sales/purchase History Median=60 minutes, Range 30-180 minutes Patient recruitment Not recorded Patient survey Not recorded Pharmacist Quiz Median=9 minutes, Range 3-30 minutes Assistant Quiz Median=6.5 minutes, Range 2-10 minutes End of trial interview Estimated median 15 minutes, Range 5 –40 minutes The audit form includes some information that duplicates data provided by the pharmacies (as a validation), independent assessments of quality, demographics about the practice and 8 questions that might otherwise be added to the wound care profile to be answered by the pharmacist as a self audit. It is estimated that these questions would take between 5 and 10 minutes to answer. Therefore, if the package were to be conducted as a self audit, excluding the customer recruitment and survey, the median pharmacy time taken for data collection would be in the vicinity of 3 hours 40 minutes (Table 7.4). In very small pharmacies, the audit could take less than 2 hours, however in very large pharmacies with a lot of stock, the audit could take almost 10 hours.

Table 7.4 Estimates of the amount of time required to conduct the data collection for self audit of wound care services

Minutes to complete Data collection task Median Minimum MaximumAudit visit form 8 questions only (estimate) 7.5 5 10 Profile form 30 10 60 Customer log based in median, minimum and maximum number of customers at 1 minute/customer

12.5 2 24

Stock holdings 60 20 120 Sales/purchase History 60 30 180 Pharmacist Quiz/pharmacist 9 3 30 Assistant Quiz/assistant 6.5 2 10 No. pharmacists/site 2 1 4 No. pharmacy assistants/site 5 1 7 Pharmacist time x No. pharmacists 18 3 120 Assistant time x No. assistants 32.5 2 70 Total time to collect data 220.5 72 584

This time does not include any data entry, data aggregation or data analysis.

29

7.3 POST-PILOT INTERVIEWS The common themes extracted from the detailed responses from the post pilot semi-structured interviews (see Appendix C) related to the project materials, the feasibility of the data collection, perceived benefits and needs identified, and the pharmacies experience of this practice-based research. In the post pilot interviews, none of the sites reported difficulty in understanding the purpose of the study. The study itself was seen as interesting and useful because it focused attention on the wound care category of the pharmacy. In all but 3 sites, the materials were felt to be straight forward and easy to use, although, this understanding was aided by the face-to-face discussions with the researcher introducing the materials (particularly in one site where the project was really run by pharmacy assistants, who did not use the instruction sheet because they found the amount of text daunting). Sites reported that the data collection and processes involved in the study were daunting until they were explained by the researched during a face-to-face visit. Four sites explicitly mentioned the glossary showing which dressings belonged in which category as being particularly helpful. Some thought the glossary was a form of education in itself. One site found the flow chart to be a useful summary while others found that the data requested identified areas for improvement in POS and other practice areas. One site felt all the paperwork except the customer log needed streamlining (but specifics not given), especially the consenting process for the customer survey (this site did not recruit a customer for the survey). Another site found that the ‘stock turnover’ form was a bit confusing (assumed to mean the stock sales/purchases history form), while another site, where the study was run by pharmacy assistants, would have preferred a summary/important point sheet instead of the instruction sheet. Time factors were raised by 3 sites as a problem associated with the materials – one site felt that the time required for the data collection was understated (this site had a very large stock holding). Note that the information sheet provided to the pharmacies with the consent form (see Appendix B) indicated that a time commitment of approximately 10 hours was estimated. One site, where the data collection started late, found it difficult to provide the information in the timeframe. [Indeed, a number of sites cited time pressures as the reason for not completing the stock sales/purchases history form.] The time pressures were partly due to the PAN Pharmaceutical recall and to personnel pressures (e.g. through ill health or holidays). Overall, sites found that the data collection was not difficult but it was time consuming. The stock holdings and sales/purchases data were felt to be the most time consuming, often since POS systems did not facilitate extracting data in the dressing type categories requested and because these types on information were not routinely collected. The large volume of stock held in some sites meant that the stock holding information was very time consuming. The two most difficult data items to collect were the sales/purchase history data and recruiting customers for the customer survey. Most sites reported that their POS systems were not coded to easily obtain this data while getting purchases reports from wholesalers was not found to be feasible. Interestingly, a number of sites saw no role for POS to collect this kind of data or other data (e.g. customer log type information) for practice improvement activities. Partly, this seemed to be related to the difficulty or the time required to ‘program’ the POS collect additional information or to categorise products as required in this project. While the benefits of monitoring outcome i.e. wound healing, were seen a positive by some interviewees, the length of the consent documents and the pharmacists’ impression of a customers willingness (customer trust was felt to be an issue here) or ability to take part in a

30

telephone survey conducted by someone the customer did not know were two barriers to customer recruitment. Another barrier was trying to take that extra time during a customer contact to undertake the consenting process when pharmacist time was short and when the customer had completed his or her transaction and wanted to leave the pharmacy. Keeping staff motivated to seek customer recruitment was also an issue, particularly when staff had competing priorities (e.g. PAN Pharmaceuticals recall, accreditation, key personnel away). One site noted that low staff confidence in approaching customers to participate in the survey was also a barrier. A number of interviewees felt that the consumer survey might have worked better with a shorter consent process (not as lengthy as that required by ethics committees) and if the outcome follow-up was to be conducted by the pharmacy, possibly at the next visit. All but the benchmark site felt that the review of stock holdings across the different dressing categories was the most useful indicator as it provided information about stock levels and stock range, and it also had educational benefits because staff learned which dressings belonged in which category. As one pharmacist said it forced “you to look realistically at what you’ve got and you realise that you don’t know what stuff is for”. A number of sites indicated that they might repeat the stock holdings form for their own benefit. The pharmacist as the benchmark site was more interested in the extent to which customer choice was influenced, as indicated by the customer log, although the stock holding data was also useful (to actually know stock levels and as informal education). A number of other sites also found the customer log to be useful in that they could see just what kinds of products customers actually came to the pharmacy to purchase, giving an opportunity to compare stock with sales and defined the customer base. The benefits associated with the benchmarking exercise were that: • The project forced the pharmacist to focus on the area and to realise that it was not as

efficient as it could be • Staff awareness of wound care was increased • Education was required to support the category and to increase staff confidence. • Being seen to be involved with research was good marketing/public relations, indicating

that the pharmacy was ‘cutting edge’, and enhanced the professional aspect of the service • Some thought was needed to better merchandise the category • Staffing issues needed to be resolved e.g. there was dependence on key personnel, for whom

there was no backup or that wound presented at times when staff trained in wound care were not on duty

• It was helpful in gaining QCPP accreditation • Product knowledge was increased by doing the stock check and putting stock into the

categories on the forms • Documentation practices could be improved At the time of the post-data collection interview, four sites felt that the benefits of the study outweighed the cost, although one site indicated that benefits were not direct. Seven sites did not answer this question, although a range of benefits were cited. Three sites could not say that the benefits outweighed the costs since they had not seen the feedback reports. Two of these larger sites felt that perhaps the time taken to compile the stock data did not make the process worthwhile. Pharmacists at several sites added that they spent a lot of time acting as a mentor or championing the project to staff, which might need to be factored into the cost-benefit decision. A range of needs were also identified, with the most common one being education. Mostly this concerned education of assistants to improve their product knowledge and confidence in serving wound care customers, but needs related to pharmacists knowledge and confidence were also

31

identified. A related need was one of staff confidence to become more involved in the sale of appropriate wound care products - as one pharmacist said, “wound care products tend to be bought not sold!” as a result of this lack of confidence and knowledge. Several sites indicated limitations with currently available wound care training. For rural sites &/or those with low turnover, these sites tended to miss education provided by the wound care companies. The nature of the training provided was also felt to not meet the needs of pharmacy assistants, often being at too high a level and not focusing on the basic service elements. Initially, pharmacy assistants needed simple tools to help staff give better service e.g. product selection and what type of information to seek about a wound to aid that general product selection. Complementary training and support materials were required to enable service improvement to occur small steps at a time, rather than not at all because the training was too complex. Other needs to be addressed were: • Merchandising (product display etc) in a disease state management context • Community pharmacy friendly packaging with information on product use on each unit • That a staff wound care protocol was required • The development of tools required to support pharmacy assistants in improving their wound

care services e.g. a generic staff protocol for a wound care service episode, basic decision support tools which also indicate when more help should be sought

The pharmacies involved in this benchmarking project had not linked the process to CQI and were please that the activity could fulfill this QCPP requirement. Most pharmacies had had little experience participating in research and indicated that they would participate in this type of project again if the topic was interesting/relevant and if they could overcome some of the time pressures experienced with this study. The role of the researcher making face-to-face visits to support the project was considered to be a project enabler. Some suggestions for improving the study were that pharmacy assistants should be empowered so that they could be involved in and run the data collection without the continual direction of the pharmacist. Practice improvement projects such as this one were felt to need a team to run the project not just one person. More extensive use of a research mentor to visit sites to explain the project to the all staff and keep things on track would be helpful and take some of the mentoring burden from pharmacists, particularly where the style of project involves the whole team.

7.4 SECOND EXPERT PANEL MEETING The presentation and notes of the discussion at the second expert panel meeting are shown in Appendix E. The panel members considered the draft recommendations and made additional suggestions where were included in the conclusions and recommendations stemming from this project. The panel found that a main benefit of the project was that it raised awareness in the pharmacies about wound care for a relatively small expenditure of pharmacy staff time. The panel’s main concern was that there was a lack of confidence and expertise among pharmacy staff (assistants and some pharmacists) that contributed to a lack of willingness of staff to engage with wound care customers to assist the customers in choosing and using more appropriate wound dressings. Lack of confidence was felt to be related to the lack of suitable training and service protocols and tools. The panel agreed that setting the standards for various levels of service was also required, and panel members agreed to take part in this task should it be funded. Panel members expressed some concern over the lack of documentation of wound care services particularly as this prevented pharmacies from systematically following up the outcome of wound care.

32

The panel felt that overall, the process of developing indicators was worthwhile, and that the model could be applied to other areas of practice, but that the need for mentoring to facilitate these type of projects needed to be factored in to the costs. Further work was required in the development of standards.

7.5 FOLLOW-UP OF FEEDBACK REPORT The pharmacies were telephoned between 19 and 26 days after they would have received the benchmarking report. The responses are summarised in Table 7.5. Of the top seven sites based on the combined quality score, 6 had read the report and 4 indicated they had identified areas for improvement and/or had plans for change. Of the bottom seven, 3 had read the report (4 if the intention to read is included), one had identified an area for improvement but none had any plans for change. Five rural and four metropolitan sites had read the report.

Table 7.5 Findings at follow-up of feedback report

Site Quality score*

Read? Action taken or planned? Comments

M01 78.97 Yes None mentioned Encouraging to staff to be benchmark; found benefit in the whole process

M03 53.67 Yes Plan to make changes, meeting scheduled to discuss report with proprietor

Disappointed did not perform better as considered themselves to be a practice leader

M04 59.14 Yes Did find areas to address Concerned over bad score in mystery shop

M05 36.24 Yes - skimmed

Sounded unlikely since indicated that report seemed to have gone missing & did not sound concerned

Report had not had a chance to affect practice yet

M06 60.93 No Too busy, had not looked at it yet

M08 37.41 No but had taken it home to read

A friend had inadvertently taken the report from home in a pile of papers and not yet returned it

M11 21.22 No No chance to look at it – had recently lost 2nd pharmacist & had a backlog of 1mth’s non-urgent mail

R01 52.67 Yes Plan to put improvement strategies in place, since up for QCPP accreditation, & process helps CQI

Pleased to see did quite well. Already sent staff member to training

R02 49.67 Yes No clear plan of action yet Found report very interesting; said it was helpful

R04 26.59 No R05 52.38 Yes Plan to use report to help – already

sent a staff member to training, who is going to be an in-store mentor for rest of staff

Flicked through report, not read in detail yet

R06 36.33 Yes - browsed No action plans as yet, business in process of being sold

Report seemed very interesting and worthwhile

R07 44.95 Not sure Unlikely – researcher has never spoken with proprietor, only staff

No read by staff, probably in proprietor’s mail

R08 33.02 Yes Didn’t sound likely, although proprietor said had identified a need for more staff training

Pharmacist involved with project indicated that the pharm-acy’s standing was pretty much as expected (seemed satisfied with that!)

* from Combined Quality Score

33

8. RESULTS OF PHASE 3 – PILOT STUDY FINDINGS

In order to undertake benchmarking, each site must be able to compare itself to the others and the benchmark (the leading site). Consequently, results are presented per site as well as in an overall form. The benchmark site in this study was M01, although M03 and M04 were thought to have a more advanced wound care practice.

8.1 POTENTIAL INDICATOR MEASURES

8.1.1 AUDIT VISIT

The data collected at the audit visit was largely observational. Data were recorded about the wound care section layout including location of the wound care section relative to other areas of the pharmacy, the nature of the display and the stock holdings. A global assessment of quality was also made.

8.1.1.1 Layout of wound care section

Finding the location of the wound care section was not always easy - 42.9% of pharmacies had no sign indicating where wound care or first aid products were located (3 of the 5 sites were QCPP accredited per the wound care profile) although at one site, the display was very visible. Four sites (28.6%) had signs indicating “First Aid” and the sign at 4 other sites said “Wound Care”. To reach the wound care area from the dispensary, a pharmacist would have to take, on average, almost 9 steps (mean 8.79 range 4 to 15 steps). The distance of the wound care section from the dispensary did not differ significantly (p=0.823) although the median distance from the dispensary was highest in the pharmacies where the sign read “Wound Care” (Figure 8.1), which is possibly related to pharmacy size but numbers were too small to adjust for size.

446N =

Type of signage

Wound CareFirst AidNone

Ste

ps to

wou

nd c

are

16

14

12

10

8

6

4

2

Figure 8.1 Box plot (showing median (black line), interquartile range (grey box) and

outliers) of distance from dispensary versus pharmacy signage of wound care display.

From the dispensary, 6 pharmacists (42.9%) could see all or most of the wound care display and any customers browsing the section while the view at 5 sites (35.7%) was partially obstructed although any customer looking in the wound care vicinity could still be seen there.

34

At 3 sites (21.4%), the wound care section was partly obscured and the pharmacist could not see customers in the section. Two of these sites had no signs for the section and one was signed “first aid”. Although not significant (p=0.214), there was a trend towards less visible wound care sections being further from the dispensary (Figure 8.2).

653N =

How visible is wound care from dispensary

Can see most/all of section

Partly hidden but see customers

Partly hidden, customers not seen

Ste

ps -

disp

ensa

ry to

wou

nd c

are

16

14

12

10

8

6

4

2653N =





Ste

ps -

disp

ensa

ry to

wou

nd c

are

16

14

12

10

8

6

4

2

Figure 8.2 Box plot showing distance from dispensary versus visibility of wound

care display from the dispensary. The average amount of pharmacy shelf space dedicated to wound care or first aid was 9.7 linear metres (median 8.1 metres, range 3.6-21.0). The average amount of space for first aid products was 4.7 metres (median 2.9 metres, range 1.2-16.0), and for wound care products 5.0m (median 3.6 metres, range 1.8-15.0). The proportion of total space set aside for wound care products was, on average, 54.8% (range 57.4 range 15.4-87.5). Again, both the total shelf space and the proportions for wound care versus first aid varied across the sites (Figure 8.3).

0

20

40

60

80

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

% o

f tot

al d

ress

ing

shel

ves 0

5

10

15

20

25To

tal d

ress

ing

shel

ves

(m)Wound Care%

First Aid%

Total dressing shelf (m)

0

20

40

60

80

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

% o

f tot

al d

ress

ing

shel

ves 0

5

10

15

20

25To

tal d

ress

ing

shel

ves

(m)Wound Care%

First Aid%


Figure 8.3 Linear metres of shelf space for wound care and first aid products and

the percentage occupied by each product type

35

Both pharmacy size and whether the site was rural or metropolitan influenced the amount of shelf space given over to first aid (p=0.019 and 0.040 respectively, Mann Whitney U tests) (Table 8.1). Pharmacy size also influenced total shelf space (p=0.006) but not the wound care shelf space nor the proportion of shelf space for wound care. A rural versus metropolitan location also influenced the proportion of shelf space for wound care (p=0.047) (possibly due to the influence of the 3 higher level, metro sites) but not the total amount of shelf space nor the amount of shelf space for wound care.

Table 8.1 Median amount and percentage of dressings shelf space compare by pharmacy size and rural and metropolitan location

Pharmacy size Location <200 m2 >200 m2

Location overall

Median N Median N Metropolitan 1.80 3 2.90 4 2.15 Rural area 2.10 2 9.00 5 7.00

Shelf space for first aid dressings Overall 1.80 3.00

Metropolitan 2.80 3 7.80 4 3.35 Rural area 3.90 2 3.50 5 3.60

Shelf space for wound care dressings Overall 3.35 5.00


Total dressings shelf space

5.40 10.00 Metropolitan 60.91 3 77.67 4 65.11 Rural area 65.15 2 30.00 5 44.44

% of total dressing shelf for wound dressings Overall 63.64 50.00

Neither signage nor how visible the wound care section was from the dispensary were related to any shelf space for dressings variables. All but 2 sites (14.3%, M01 and R08) used manufacturers’ displays/shelving aids – 2 sites used a lot of these displays while the remaining 10 used some manufacturers’ displays. The extent that manufacturers’ displays were used was related to total shelf space for dressings and shelf space for wound care products (rho=-0.564 p=0.036 and rho=-0.631 p=0.015 respectively) but not first aid shelving or percentage of dressing shelf space for wound care. Sites with the smallest amount of total dressing shelving used a lot of manufacturers’ displays while sites that had no manufacturers’ displays had more wound care shelving (Figure 8.4). While this finding was influenced by the benchmark site (with no manufacturers’ displays and almost twice as much wound care shelving than any other site), the relationships were still approached significance after excluding M01 (rho=-0.530 p=0.062 and rho=-0.492 p=0.087). At audit, only one site, the benchmark site, displayed easily visible information for wound care product selection; the pharmacy personnel had developed this information themselves. At a post-trial interview visit, another site (R02) drew the researchers’ attention to a product selection poster a little to one side of the wound care section. The poster was less obvious and a bit faded (from prolonged display), and so was overlooked at audit. Since wound care products are odd shapes and at time difficult to display, the neatness and arrangement of wound care stock was assessed. The first aspect considered was whether the wound care products were all together – 2 sites (14%) managed this well (the benchmark site and M03), 9 sites (64%) were mostly able to arrange wound care products together while 3 sites (21%, M08, M11 and R06) did not really have the wound care products together (e.g. they were interspersed with tapes, bandages and first aid). The second aspect was whether the

36

different products could be distinguished by looking at the display. No site was able to successful display all products, but half of the sites were mostly able to achieve this (M01, M03, M04, R01, R02, R05, R06). For the remainder, some products had to be pulled out to see what they were. The third aspect was whether there were part packs of old-looking stock (e.g. that might be leftovers from a particular order and did not look like part of the usual range) – all sites had stock like this.

0

2

4

6

8

10

12

14

Not at all Somewhat A lot

Use of manufacturers' displays

Line

ar s

helf

spac

e (m

)

Median shelf space for wound care (m)

Median total dressing shelves (m)

Figure 8.4 Median dressing shelf space versus the extent of use of manufacturers’

display/shelf aids In terms of the stock ranges carried (Table 8.2), all sites carried multiple brands of passive dressings and first aid products in multiple sizes, with all but one carrying more than 10 units. All sites carried at least one brand of film and hydrocolloid dressings although not all sites carried more than one size of these dressings. For hydrogels, half of the sites carried more than one brand but the majority kept only a small number of units of stock. Ten sites did not carry cadexomer iodine or hydrofibre dressings and just over half of the sites carried any zinc paste bandages. These latter 3 dressings also had the lowest mean stock range scores and the lowest overall stock level scores. Next to passive dressings and first aid, films had the highest stock level and stock range scores. Foams, hydrocolloid, hydrogel, polymer and alginate dressings had intermediate scores.

Table 8.2 Overall stock levels held by product type category per audit

% sites where dressing stocked Mean [median (range)] scores Product category

No. of brands stocked >1 size No. of units Stock range Stock level

Films 1 brand =21.4% >1 brand =78.6%

92.9% 5-10 =14.3% >10 =85.7

5.4 [6 (2-6)] 15.7 [18 (6-18)]

Foams None =28.6% 1 brand =35.7% >1 brand =35.7%

60.0% <5 =50.0% 5-10 =20.0% >10 =30.0%

3.0 [2 (0-6)] 6.1 [3 (0-18)]

Hydrocolloids 1 brand =42.9% >1 brand =57.1%

78.6% <5 =28.6% 5-10 =42.9% >10 =28.6%

4.7 [6 (2-6)] 10.0 [12 (2-18)]

Hydrogels None =7.1% 1 brand =42.9% >1 brand =50%

53.8% <5 =46.2% 5-10 =38.5% >10 =15.4%

3.8 [3.5 (0-6)] 7.1 [5 (0-18)]

Polymer dressings

None =21.4% 1 brand =57.1% >1 brand =21.4%

81.8% <5 =27.3% 5-10 =27.3% >10 =45.5%

3.3 [4 (0-6)] 7.3 [6 (0-18)]

37

Table 8.2 continued

% sites where dressing stocked Mean [median (range)] scores Product category

No. of brands stocked >1 size No. of units Stock range Stock level

Alginates None =21.4% 1 brand =42.9% >1 brand =35.7%

54.5% <5 =36.4% 5-10 =18.2% >10 =45.5%

3.1 [2 (0-6)] 6.9 [5 (0-18)]

Hydrofibre dressings

None =71.4% 1 brand* =28.6%

75.0% 5-10 =50.0% >10 =50.0%

1.0 [0 (0-4)] 2.6 [0 (0-12)]

Cadexomer Iodine

None =71.4% 1 brand* =28.6%

100.0% <5 =25.0% 5-10 =50.0% >10 =25.0%

1.1 [0 (0-4)] 2.3 [0 (0-12)]

Zinc paste bandages

None =42.9% 1 brand =42.9% >1 brand =14.3%

12.5% <5 =75.0% >10 =25.0%

1.5 [2 (0-6)] 2.6 [2 (0-18)]

Passive dressings

>1 brand =100% 100.0% 5-10 =7.1% >10 =92.9%

All sites scored 6

17.6 [18 (12-18)]

Simple first aid products

>1 brand =100% 100.0% >10 =100.0% All sites scored 6

All sites scored 18

* only 1 brand available Using the scoring scheme, the maximum possible stock range score is 62 and the maximum possible stock level score is 186 (the maximum stock range and stock level scores for each wound product category is 6 and 18 respectively except for hydrofibres and cadexomer iodine (4 and 12 respectively)). While sites M01 and M04 had stock in each category, the benchmark site (M01) carried more hydrocolloid dressings (as seen by the stock range score in Table 8.3). M08 had the narrowest stock range (only keeping stock in 5 out of 11 categories) followed by M05. For the 4 non-advanced wound care pharmacies (M05-M11), there are 17 shaded squares in Table 8.3, compared to 19 shaded squares for 7 rural sites.

Table 8.3 Stock range and stock level score for each product category for each site

Site Stock range score / Stock level score for each dressing product category Films Foams Hydro-

colloid Hydr-ogels

Poly-mer

Algin-ates

Hydr-ofibre

Cadexomer Iodine

Zinc Paste b’age

Pass-ive

First aid

Sum of stock range score

Sum of stock level score

M01 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 4 / 12 4 / 8 2 / 6 6 / 18 6 / 18 58 170 M03 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 4 / 8 0 / 0 6 / 18 6 / 18 6 / 18 58 170 M04 6 / 18 6 / 18 4 / 12 6 / 12 6 / 18 6 / 12 4 / 12 4 / 8 2 / 2 6 / 18 6 / 18 56 148 M05 6 / 18 2 / 2 2 / 2 2 / 4 0 / 0 0 / 0 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 24 62 M06 6 / 18 0 / 0 6 / 12 2 / 2 4 / 4 4 / 4 0 / 0 0 / 0 2 / 2 6 / 18 6 / 18 36 78 M08 6 / 18 0 / 0 4 / 8 2 / 2 0 / 0 0 / 0 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 24 64 M11 4 / 8 0 / 0 6 / 12 4 / 4 4 / 8 2 / 4 2 / 4 0 / 0 0 / 0 6 / 18 6 / 18 34 76 R01 6 / 18 6 / 6 2 / 2 2 / 2 4 / 8 2 / 2 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 34 74 R02 2 / 6 2 / 2 6 / 12 2 / 2 4 / 8 6 / 6 0 / 0 0 / 0 2 / 2 6 / 12 6 / 18 36 68 R04 4 / 8 4 / 4 4 / 4 6 / 12 4 / 4 2 / 2 0 / 0 0 / 0 2 / 2 6 / 18 6 / 18 38 72 R05 6 / 18 2 / 2 2 / 4 6 / 6 2 / 6 2 / 6 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 32 78 R06 6 / 18 6 / 12 6 / 6 6 / 12 4 / 4 0 / 0 0 / 0 4 / 4 3 / 3 6 / 18 6 / 18 47 95 R07 6 / 18 0 / 0 6 / 12 3 / 6 2 / 6 2 / 6 0 / 0 4 / 12 2 / 2 6 / 18 6 / 18 37 98 R08 6 / 18 2 / 4 6 / 18 0 / 0 0 / 0 6 / 18 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 32 94 Key: shaded cells – no stock kept

38

Once the 3 high level metropolitan pharmacies are excluded (M01-M04), there is a tendency for rural pharmacies to have a broader stock range and to have greater stock levels overall (p=0.127 and p=0.155) (Figure 8.5). For these sites, there was no relationship between pharmacy size (greater or less than 200m2) and stock range or stock level (p=0.407 and p=0.522 respectively).

74N =

Rural areaMetropolitan

Sto

ck ra

nge

scor

e

50

40

30

2074N =


Tota

l sto

ck le

vel s

core

110

100

90

80

70

60

50

Figure 8.5 Boxplot comparing stock range and stock levels for rural and

metropolitan pharmacies (excluding advanced wound care pharmacies)

Including all sites, there was some suggestion that sites with no signs for the wound care section had a smaller stock range and lower stock levels, compared to sites where signs read ‘wound care’, but this was not an obvious trend (Figure 8.6).

446N =

Signs for wound care section

Woundcare1st AidNone

Sto

ck ra

nge

scor

e

70

60

50

40

30

20446N =

Signs for wound care section


Tota

l sto

ck le

vel s

core

180

160

140

120

100

80

60

40

Figure 8.6 Boxplot comparing stock range and stock levels versus signage of the

wound care section The wound care stock range score was correlated with the steps a pharmacist has to take to reach the wound care section from the dispensary (Spearman’s rho = 0.482, n=14 p=0.081). The linear metres of shelf space for wound care and the total linear metres of shelving for dressings were related to: The stock range score (Spearman’s rho = 0.743 p=0.002 and rho=0.679 p=0.008,

respectively) The stock level score (Spearman’s rho = 0.630 p=0.016 and rho=0.559 p=0.038,

respectively) Neither stock score was related to shelf space for first aid products nor the percentage of total dressings shelves for wound care products.

39

8.1.1.2 Perceived quality measures

Based on the findings at the audit visit, the auditor made quality assessments on 4 dimensions, each with a score out of 100 (a visual analogue scale): Overall level of quality of wound care service (poor to excellent) The wound care service level provided (rudimentary (basic first aid only) to advanced

(e.g. treat complex chronic wounds) The extent to which space and facilities met the needs of wound care service level

provided (not at all to completely) Whether the wound care display was organised to aid customer self-selection of dressings

(does not assist to fully assists) The frequency distributions for these quality assessments are shown in Figure 8.7. Ratings were generally spread over the full range for ‘overall quality’ (median 50), ‘service level’ (median 49) and ‘space/facilities needs met’ (median 45) but the ratings for ‘display aids self-selection’ were generally lower (median 32).

Display aids self-selection

9070503010

Freq

uenc

y

3.5

3.0

2.5

2.0

1.5

1.0

.5

0.0

Std. Dev = 18.86 Mean = 35

N = 14.00

Space and facilities needs met

9070503010

Freq

uenc

y

5.0

4.0

3.0

2.0

1.0

0.0

Std. Dev = 24.44 Mean = 48

N = 14.00

Overall woundcare service quality

9070503010

Freq

uenc

y

3.5

3.0

2.5

2.0

1.5

1.0

.5

0.0

Std. Dev = 24.13 Mean = 54

N = 14.00

Woundcare service level

9070503010

Freq

uenc

y3.5

3.0

2.5

2.0

1.5

1.0

.5

0.0

Std. Dev = 25.29 Mean = 50

N = 14.00

Figure 8.7 Frequency distributions for 4 quality assessments made at audit visit

showing mean and standard deviation

When the ratings scores were summed, M11 had the lowest total score followed by R04 and R06. Site M01 was rated most highly, followed by M03, M04, R02 and R05. The overall quality rating and the service level score were very similar for all but 2 sites (R06 and R08) (Figure 8.8 A), but the space and facilities needs and display for self-selection ratings varied more from the overall quality rating (Figure 8.8 B).

40

0

10

20

30

40

50

60

70

80

90

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Aud

it R

atin

g sc

ore

Overall quality Service levelA

0

10

20

30

40

50

60

70

80

90

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Aud

it R

atin

g sc

ore

Overall qualitySpace & facilities needsDisplay aids self-selection

B

Figure 8.8 Perceived quality ratings at audit (A) overall and service level; (B) overall,

space and facilities needs, and display for self-selection The quality assessment ratings correlated with each other with Spearman’s correlation coefficients ranging from 0.678 to 0.949 (Table 8.4).

Table 8.4 Spearman’s correlations between quality assessments at audit (n=14)

Quality assessment Correlation coefficient Overall quality Service level (rudimentary to advanced) 0.949 p<0.0001 Service level Space and facilities needs met 0.729 0.780 p=0.003 p=0.001

Space & facility needs met

Wound care display aids self-selection 0.822 0.839 0.678 p<0.001 p<0.0002 p=0.008

The quality assessment ratings did not differ significantly between smaller and larger pharmacies (p=0.350, 0.385, 0.463 and 0.256 respectively) or between rural and metropolitan pharmacies (with (p=0.749, 0.442, 0.848 and 0.949 respectively) or without the 3 more advanced wound care pharmacies (p=0.129, 0.393, 345 and 0.218 respectively)). Similarly, the distance from the dispensary to the wound care section, the linear metres of first aid

41

shelving and total dressing shelf space did not correlate with any quality assessment at audit. Linear metres of wound care shelf space did correlate with the overall quality assessment (rho=0.582, p=0.029) but not with any other quality assessment. The percentage of total dressings shelves for wound care increased with the overall quality rating (rho=0.594, p=0.025), the service level rating (rho=0.587, p=0.027) and the display aiding self-selection rating (rho=0.477, p=0.084), but was not significantly related to the space and facility rating. As the stock range score and total stock level scores increased, so too did the ratings of: • Overall service quality (rho=0.556 p=0.039and rho=0.721 p=0.004, respectively) • Service level rating (rho=0.501 p=0.068 and rho=0.615 p=0.019, respectively) In sites where the wound care section was signed as “Wound care”, quality assessments of space and facility need being met and display aiding self-selection were higher than those signed as first aid or those with no sign (Figure 8.9). These trends were also seen for overall quality and service level ratings.

446N =

Sign for wound care section


Ove

rall

qual

ity ra

ting

120

100

80

60

40

20

0446N =



Serv

ice

leve

l rat

ing

120

100

80

60

40

20

0

446N =



Spac

e &

faci

litie

s ne

ed m

et

120

100

80

60

40

20

0446N =



Dis

play

aid

s se

lf-se

lect

ion

120

100

80

60

40

20

0

p=0.170 p=0.120

p=0. 076 p=0.027

Figure 8.9 Boxplots comparing quality assessments at audit for the type of signage

of the wound care section

At audit, only 3 sites (21%) (M01, M03 and M04) said they had written procedures for wound care, with the auditor sighting these at M01 and M03. These 3 sites were felt by the auditor to offer a more advanced service, and the sites had been connected with a previous wound care study where these were developed.

8.1.2 PROFILE

The wound care profile was completed by 13 of the pilot pharmacies. For the most part, the profile was completed by a proprietor or manager.

42

8.1.2.1 Pharmacy characteristics and workload

The trading hours of the pharmacies ranged from 48.5 to 112 hours/week, with a median of 56 hours (mean 63.2 hours) (Figure 8.10). The 4 sites opening 48.5 hours/week were all rural sites and the benchmark site had the longest opening hours, so that the difference between opening hours for rural and metropolitan sites was significant (p=0.020). About half (53.8%) of pharmacies studied were open after 6pm on weekdays and the majority (61.5%) where open at some stage between 5pm Saturday to Monday morning.

Trading hours/week

112.

510

7.5

102.

597

.592

.587

.582

.577

.572

.567

.562

.557

.552

.547

.5

Freq

uenc

y

5

4

3

2

1

0

Figure 8.10 Frequency distribution of trading hours/week

Just over half of the sites dispensed up to 1200 prescriptions/week (Figure 8.11). One site dispensed more than 2000 prescriptions/week, while the benchmark site filled between 1201 and 2000 prescriptions/week. To some extent, prescription volume is related to trading hours (Spearman’s rho=0.639 p=0.019) (Figure 8.11).

Number of prescriptions dispensed/week

2001-30001201-2000801-1200301-800300 or less

Cou

nt

6

5

4

3

2

1

0

Number of prescriptions dispensed/week

6543210

Trad

ing

hour

s/w

eek

120

110

100

90

80

70

60

50

402001-30001201-2000801-1200301-800300 or less

R06R04

M06

M05

R08R02

M11

M01

M03

R05

M08

R01

M04

Figure 8.11 Number of prescriptions dispensed/week and prescriptions/week versus

trading hours/week

43

The pilot sites had, on average, 1.8 effective full-time equivalent (EFT) pharmacists (median 2, range 1-3) and 4.8 EFT pharmacy assistants (front of shop and dispensary) (median 4, range 1-12) (Figure 8.12).

No. EFT pharmacists

3.02.52.01.51.0

Freq

uenc

y10

8

6

4

2

0

Std. Dev = .53 Mean = 1.8

N = 13.00

No. EFT pharmacy assistants

12.010.08.06.04.02.0

Freq

uenc

y

5

4

3

2

1

0

Figure 8.12 Frequency distributions for number of EFT pharmacists and assistants

There was more than one pharmacist on duty for an average of 26.8 hours/week (median 30, range 0-50). Assuming that for these hours there was only one additional pharmacist, the median number of estimated total pharmacist hours/week was 89.5 hours (mean 90.1, range 48.5-126.5 hours). Dividing the total pharmacist hours by the number of EFT pharmacists gave hours/week/EFT pharmacist, where the median was 48.5 hours (mean 50.8, range 40 to 63.25 hours). The distributions across the sites are shown in Figure 8.13.

0

20

40

60

80

100

120

140

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Hou

rs/w

eek

Total p'cist hrs hrs/EFT pharmacist

Figure 8.13 Estimated total pharmacist hours/week and hours/week/EFT pharmacist

for each site

Among these pharmacies, the number of EFT pharmacists did not significantly correlate with the number of prescriptions dispensed/week (Spearman’s rho= 0.438, p=0.135) but estimated total pharmacist hours did increase as prescription numbers increased (rho=0.718, n=13 p=0.006) while the number of EFT pharmacists increased with trading hours (rho= 0.560, p=0.047) (Figure 8.14). The ratios of estimated total pharmacist hours per EFT pharmacist and estimated total pharmacist hours per actual pharmacist were not related to the number of prescriptions dispensed/week (rho=0.373 n=13 p=209 and rho=-0.268 n=12 p=0.400 respectively). The number of EFT pharmacists increased as the EFT of pharmacy assistants increased (rho= 0.528, p=0.064) and the hours/week when more than 1 pharmacist was on duty (rho= 0.486, p=0.092) (Figure 8.15). The number of hours/week where there was more than one pharmacist on duty did not relate to either prescription numbers or trading hours

44

(Figure 8.15) nor did the number of EFT pharmacy assistants was relate to prescription numbers or trading hours. There was a trend however, for the EFT number of pharmacy assistants to increase as the shop size increased (rho=0.418, n=13 p=0.155) (Figure 8.15).

No. of prescriptions/week

2001

-300

0

1200

-200

0

801-

1200

301-

800

≤30

0

EFT

No.

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

0.5

R08

R06

R05R04

R02R01

M11

M08

M06

M05 M04M03

M01

Trading hours/week

120

110

100908070605040

EFT

No.

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

.5

R08

R06

R05R04

R02R01

M11

M08

M06

M05M04

M03

M01


Est

imat

ed to

tal p

'cis

thou

rs/w

k 140

120

100

80

60

40

R08

R06

R05

R04

R02

R01

M11M08

M06

M05

M04

M03M01

1200

-200

0

801-

1200

301-

800

≤30

0

2001

-300

0

C

BA

D

Size of pharmacy (m2)

>300 200-300100-200≤ 100

No.

EFT

pha

rmac

y as

sist

ants 12

10

8

6

4

2

0

R08

R06

R05

R04R02

R01M11

M08M06

M05

M04

M03M01


2001

-300

0

1200

-200

0

801-

1200

301-

800

≤30

0

EFT

No.

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

0.5

R08

R06

R05R04

R02R01

M11

M08

M06

M05 M04M03

M01

Trading hours/week

120

110

100908070605040

EFT

No.

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

.5

R08

R06

R05R04

R02R01

M11

M08

M06

M05M04

M03

M01


Est

imat

ed to

tal p

'cis

thou

rs/w

k 140

120

100

80

60

40

R08

R06

R05

R04

R02

R01

M11M08

M06

M05

M04

M03M01

1200

-200

0

801-

1200

301-

800

≤30

0

2001

-300

0

C

BA

D

Size of pharmacy (m2)

>300 200-300100-200≤ 100

No.

EFT

pha

rmac

y as

sist

ants 12

10

8

6

4

2

0

R08

R06

R05

R04R02

R01M11

M08M06

M05

M04

M03M01

Figure 8.14 Staffing versus workload: A EFT number of pharmacists and B. Estimated total pharmacist hours/week versus prescriptions/week; C. EFT number of pharmacists versus trading hours/week; EFT number of assistants versus pharmacy size

Hours/week where >1 pharmacist

5550454035302520151050-5

No.

EFT

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

.5

R08

R06

R05R04

R02

R01

M11

M08

M06

M05M04

M03

M01


5550454035302520151050-5

No.

EFT

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

.5

R08

R06

R05R04

R02

R01

M11

M08

M06

M05M04

M03

M01


5550454035302520151050-5

Trad

ing

hour

s/w

eek

120

110

100

90

80

70

60

50

40

R08R06

R05

R04R02

R01

M11M08M06

M05

M04M03

M01


5550454035302520151050-5

Trad

ing

hour

s/w

eek

120

110

100

90

80

70

60

50

40

R08R06

R05

R04R02

R01

M11M08M06

M05

M04M03

M01

Figure 8.15 Number of hours/week when there was more than one pharmacist on

duty versus number of EFT pharmacists and trading hours/week

45

Since recent graduates of the Victorian College of Pharmacy were likely to have received formal wound care training as part of their undergraduate course, the sites were asked to indicate the number of pharmacists who had been registered less than 5 years and those registered 5 years or more. The sum of these 2 categories was used to calculate the actual number of pharmacists working in a pharmacy. Almost two thirds of pharmacies (61.5%) did not have pharmacists who had registered in the last 5 years. At no site were there only recently registered pharmacists. In the remaining 4 sites, there was a mix of recent graduates and more experienced pharmacists. One site did not answer this question. The benchmark site (M01) and the other pharmacies with a more advanced service (M03, M04) had more recent graduate on staff than other sites (Figure 8.16).

0

1

2

3

4

5

6

7

8

9

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Num

ber o

f pha

rmac

ists

0

10

20

30

40

50

60

70

Hou

rs/w

eek

Registered<5 yrs Registered 5 yrs or more Total p'cist hrs/No. p'cists

Figure 8.16 Number of pharmacists by time since registration and ratio of number of

total pharmacist hours (trading hours + hours when >1 pharmacist) : total number of pharmacists

Metropolitan pharmacies tended to have more pharmacists to cover the pharmacist hours (Figure 8.16). Ten of the 13 responding pharmacies were accredited with QCPP. Of those that were not accredited, one had completed more than 50% of the required work whilst the remaining two had achieved less than 50%. Community pharmacies extend services into residential aged facilities and community nursing organizations. Of the sites completing the profile, 46% (M01, M04, M08, R01, R02, R04) indicated that the pharmacy supplied wound care products to residential aged facilities and 18.2% (M01 and M04) supplied wound care products to community nursing organizations.

8.1.2.2 Proprietor/Manager perceptions of service and quality

Proprietors or managers were asked to make the same 4 quality assessments as the auditor: • Overall level of quality of wound care service (a visual analogue scale from poor to

excellent)

46

• The wound care service level provided (rudimentary (basic first aid only) to advanced (e.g. treat complex chronic wounds)

• The extent to which space and facilities met the needs of wound care service level provided (not at all to completely)

• Whether the wound care display is organised to aid customer self-selection of dressings (does not assist to fully assists)

The frequency distributions for these quality assessments are shown in Figure 8.17. For ‘overall quality’ (median 60), the majority of proprietor/managers believed that the pharmacy was more than halfway towards providing an excellent service. The ‘service level’ median was 50, but the distribution suggests that there may be 3 levels of service (score <40, 40-65 and >65); one site indicated that the service level provided was rudimentary. The majority of pharmacies believed that their wound care space and facility needs were met (median 63), and that wound care was displayed to aid self-selection (median 69). When the ratings scores were summed, the proprietor of R05 was most critical of the service aspects, followed by R06 and R01. Site M03 rated themselves the most highly, followed by R04, M06 and M04.

Space and facilities needs met

100806040200

Freq

uenc

y

5

4

3

2

1

0

Std. Dev = 20.69 Mean = 66

N = 13.00

Display aids self-selection

100806040200

Freq

uenc

y

3.5

3.0

2.5

2.0

1.5

1.0

.5

0.0

Std. Dev = 23.94 Mean = 65

N = 13.00

Woundcare service level

100806040200

Freq

uenc

y

3.5

3.0

2.5

2.0

1.5

1.0

.5

0.0

Std. Dev = 29.64 Mean = 53

N = 13.00

Overall woundcare service quality

100806040200

Freq

uenc

y

3.5

3.0

2.5

2.0

1.5

1.0

.5

0.0

Std. Dev = 25.38 Mean = 61

N = 13.00

Figure 8.17 Frequency distributions for 4 quality assessments made by

proprietor/manager showing mean and standard deviation

Generally, proprietors/managers rated the overall quality of the service they provided as equal to or higher that the service level (ranging from rudimentary to advanced), except for one site where the service level provided was rated considerably higher than overall service quality (Figure 8.18). Agreement between ratings overall was much lower with only 2 of the 6 potential correlations between these ratings having a probability of <0.1 (Table 8.5). When

47

the service level provided was rated more highly, so too was the overall quality level, however, the extent to which space and facility needs were met declined. The actual shelf space variables (from the audit) did not correlate with the proprietor’s rating of space and facility needs. Only the amount of shelf space for wound care (not total dressings shelves nor the percentage for wound care) was related to any proprietor quality assessment, overall quality (Spearman’s rho = 0.538, p=0.058).

0

10

20

30

40

50

60

70

80

90

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Prof

ile R

atin

g sc

ore


0

10

20

30

40

50

60

70

80

90

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Prof

ile R

atin

g sc

ore


B

Figure 8.18 Perceived quality ratings per profile (A) overall and service level; (B)

overall, space and facilities needs, and display for self-selection

Table 8.5 Spearman’s correlations between proprietor’s quality assessments

Quality assessment Correlation coefficient (n=13) Overall quality Service level (rudimentary to advanced) 0.780 P=0.002 Service level Space and facilities needs met -0.241 -0.495 p=0.427 p=0.085

Space & facility needs met

Wound care display aids self-selection 0.156 0.175 0.244 P=0.611 P=0.567 p=0.421

48

The proprietor’s rating of overall quality and the level of service provided were also related to the range of stock carried, as indicated by the stock range score (rho=0.597 p=0.031 n=13 and rho=0.494, p=0.086 n=13 respectively) but not to the total volume of stock. Eight of 13 pharmacies had written information about wound care available for the customer to take away. Typically most (5) offered manufacturers pamphlets while the remaining 3 (M06, R02, R04) used computer printouts as their consumer information source. Pharmacists were asked to look back over a 2-week period and comment on any wound care transaction: 92.3% of pharmacies said that assistants sought the pharmacist’s input on at least one occasion; only 38.5% of pharmacies sought detailed histories whilst just 7.7% kept written records of consultations. In this period, 90.9% of the pilot pharmacies believed that customers had been persuaded to purchase a more appropriate dressing. The profile sought information on the proprietor/managers’ estimates of the percentage of wound care customers with various types of wounds (Table 8.6). Overall, proprietors estimated that more than twice as many wound care customers had cuts and grazes (34%) than those with burns (15%), leg ulcers/pressure sores (10%) or stitches/surgical wounds (7%). The percentage estimate for cuts and grazes ranged from 10% to 60%. For burns this range was 5% to 30%, for leg ulcers/pressure sores (0 to 24%), for stitches/surgical wounds (0% to 50%) and for people making a purchase for future use 0 to 50%.

Table 8.6 Pharmacy proprietor/manager estimates of the percentage of wound care customers with various types of wounds

Mean % of wound care customers Site None for

future use Cuts & grazes

Burns Leg ulcers or pressure sores

Stitches or surgical wounds

Other wounds

M01 10.00 40.00 20.00 15.00 15.00 0.00 M03 50.00 25.00 10.00 5.00 10.00 0.00 M04 15.00 25.00 10.00 20.00 20.00 10.00 M05 10.00 40.00 30.00 10.00 10.00 0.00 M06 17.00 21.00 14.00 24.00 24.00 0.00 M08 30.00 30.00 20.00 0.00 0.00 20.00 R01 0.00 30.00 10.00 5.00 50.00 5.00 R02 0.00 50.00 20.00 7.00 22.00 1.00 R04 10.00 10.00 R05 0.00 60.00 15.00 15.00 10.00 0.00 R06 40.00 40.00 5.00 2.00 10.00 3.00 R08 20.00 40.00 10.00 10.00 18.00 2.00 Overall mean 17.45 34.25 14.50 10.27 7.18 3.73 As the proprietor’s estimate of the percentage of wound care customers who have leg ulcers or pressure sores increased, their rating of overall service quality increased (rho=583 p=0.060 n=11) and their views on the extent to which their space and facility needs were met decreased (rho=-0.530 p=0.094 n=11). Similarly, as proprietor estimates of the percentage of stitches and surgical wound increased, satisfaction with space and facilities decreased (rho=-0.604 p=0.049 n=11). In 76.9% of pharmacies, there was an opportunity to monitor wound healing progress because wound care customers were seen more than once. Of these pharmacies, 63.6% routinely monitored progress in a given episode of wound care.

49

Proprietors were also asked about referral patterns. On average, pharmacies had referred 4.25 customers (median 4, range 0-10) to other health professionals in the last 4 weeks. Three of the pharmacies had referred 10 patients (M01, M04 and R04) and one reported (M03) referring 20% of wound care customers to other health professionals over the 4-week period. Of the 12 responding pharmacies, half reported (M01, M04, M06, M11, R04, R06) that they had customers referred to them by other health professionals for wound care services in the previous 3 months.

8.1.2.3 Stock and sales

Proprietors were asked how they selected the range of products stocked. Primary factors affecting the range of products stocked in pharmacies are categorized into four groups: • Recommendation by other health professionals (e.g. nurses, doctor, or community nursing

services) in 4 pharmacies • Advice by company representatives and manufacturers (includes supply of quality range

of products) in 5 pharmacies • Education (wound care seminars, lectures) in 2 pharmacies • Requests for specific dressings (direct requests, customer needs) in 2 pharmacies Some of the secondary factors influencing whether products were stocked were sales history and sales data, availability or level of company support, products that pharmacies are most experienced with using, banner group planograms and product costs. Eleven of 13 responding pharmacies stated that they did review their wound care product range. The primary criteria used in this review were: • Previous sales figures (8 sites) or customer demand/requests (3 sites) • Advice from company representatives (4 sites) • Pharmacy magazines, lectures and wound management leaflets (2 sites) • Product prices and prices of competitors Based on the reviews over the last 12 months all 12 responding pharmacies reported making changes to the stock range they carried. Eleven of the 14 pharmacies indicated what proportion of pharmacy turnover was related to would care products. Wound care was less than 1% of turnover for M05, M08, M11, R05 and R06 and between 1 and 2% for M06, R01 and R08. Pharmacies M01 (>5%), M03 (4-5%) and M04 (2-3%) reported that wound care products contributed to greater than 2% of their annual turn over last financial year. Generally, the percentage of turnover from wound care products increased as the following increased: • The linear metres of shelving for all dressings (Spearman’s rho=0.594, p=0.054, n=11) • The linear metres of wound care shelving (rho=0.692, p=0.018, n=11) • The percentage of total dressing shelves for wound care (rho=0.647, p=0.031, n=11) • The trading hours/week (rho=0.618, p=0.043, n=11) • The proprietor’s perception of the overall service quality provided by the pharmacy

(rho=0.685, p=0.020, n=11) • The proprietor’s perception of the service levels (rudimentary to advanced) provided by

the pharmacy (rho=0.637, p=0.035, n=11) Turnover from wound care was not related to the amount of shelving for first aid products, the number of prescriptions dispensed/week or proprietors’ perceptions of the extent to which space and facility needs were met or the arrangement of the display to aid self-selection by customers.

50

Six out of 13 pharmacies responded to having an out of stock in the last 2 weeks and 8 of these 13 supplied a second choice wound care item (dues to stock outs). Six sites (2 reporting no stock outs or substitutions) indicated that the information supplied was a ‘best guess’, 3 did not respond, and 4 gave the information resources used to make the substitution.

8.1.2.4 Human and information resources

Ten of 12 pharmacies had wound care trained pharmacy assistants. The median number of trained staff was 2 (range 0-5). Only 2 sites had more than 3 pharmacy assistants with wound care training (Figure 8.19). Proprietors reported that the majority of the trained assistants were trained within the last 2 years (Figure 8.19, Spearman’s rho=0.909, p<0.0001 n=11). The proportion of the pharmacy trading hours that wound care trained assistants were on duty varied (Figure 8.19). Overall, there was at least one wound care trained assistant on duty for a median of 50% of the trading hours (range 0-100%). Only 3 out of 9 pharmacies had at least one trained wound care pharmacy assistant on duty for the entire trading time. The benchmark site (M01) had a trained assistant on duty 75% of the trading hours but this pharmacy had the longest trading hours (112 hours). Generally, the percentage of trading hours covered by a wound care trained assistant increased as the number of trained assistants increased (Figure 8.19, Spearman’s rho=0.662, p=0.027 n=11).

No. assistants with wound care training

6543210-1

No.

ass

ista

nts

train

ed in

last

2 y

rs

6

5

4

3

2

1

0

-1

R08

R06

R02

R01M11

M08

M06

M05M04

M03

M01


6543210-1

No.

ass

ista

nts

train

ed in

last

2 y

rs

6

5

4

3

2

1

0

-1

R08

R06

R02

R01M11

M08

M06

M05M04

M03

M01


6543210-1

% o

f tra

ding

hou

rs w

ith tr

aine

d st

aff

120

100

80

60

40

20

0

-20

R08

R06

R05

R02

R01

M08

M06

M05

M04

M03

M01


6543210-1

% o

f tra

ding

hou

rs w

ith tr

aine

d st

aff

120

100

80

60

40

20

0

-20

R08

R06

R05

R02

R01

M08

M06

M05

M04

M03

M01

Figure 8.19 Scatterplots of number of wound care trained pharmacy assistants with

versus number of assistants trained in the last 2 years and percentage of trading hours when a wound care trained assistant was on duty

Assistant training was also related to the stock range carried. The stock range score at audit increased as the number of trained assistants increased (rho=0.753, p=0.005 n=12) and this relationship remained significant after the 3 more advanced sites (who carried the biggest stock range) were excluded (rho=0.730 p=0.025 n=9). The proprietor’s perception of the overall service quality provided by the pharmacy increased as the number of pharmacy assistants with wound care training and the percentage of opening hours where a wound care trained assistant was on duty increased (Spearman’s rho=0.627, p=0.029, n=12 and rho=0.543, p=0.084, n=11 respectively). Of the 12 sites responding to the question on pharmacist training, at 4 sites (M04, M06, M08, R05), no pharmacists had received wound care professional development in the last 2 years. At 4 of the 5 rural pharmacies where at least 1 pharmacist had received recent training, 100% of pharmacists were trained. In the other rural pharmacy, 1 of 2 pharmacists had had wound

51

care training in the last 2 years. In the metropolitan pharmacies, only at M11 had 2 of 2 pharmacists had recent wound care training; at M03, 1 pharmacist of 6 had recent training while at M05, 1 pharmacist of 3 had recent training. M01 did not specify the number of pharmacists with recent wound care training, but did indicate that the training activities undertaken were company presentations and short courses by the Victorian College of Pharmacy. The types of training activities listed by other sites were: • PSA or other lectures (typically by Geoff Sussman or Jan Rice) – sometimes more than a

single lecture e.g. wound care course or lecture series (5 sites) • Wound care as part of the university pharmacy course (1 site) • PAC wound care workshop (1 site) The number of pharmacists or percentage of pharmacists with wound care training was not correlated with the number of assistants with wound care training or the percentage of trading hours when wound care trained assistants were on duty. Nor were the proprietors’ ratings over overall service quality, service level provided, space and facility needs or display for self-selection related to recent pharmacist wound care training. Only 1 of 13 pharmacies had another specialist staff member providing wound care services. However, 10 of 13 pharmacies knew of other health care providers in their area, which they could refer customers to for more complex wound care but only 1 of 11 had this information documented (M01). Four of 13 sites indicated that pharmacy staff did not have information resources in the pharmacy to refer to for wound care assessment (M01, M11, R01, R05). Information resources for staff on product selection and its appropriate use were not available at M01, M05, M11 and R05. The information sources available included the Australian Pharmaceutical Formulary (APF) wound management section (M05, R08), PSA lecture notes (R01), other lecture notes (R04), Woundcare Foundation materials (M04), comprehensive manuals (R06), wound management protocols (M03), computer software (R02) or internet sites (R06), an in-house wound management file (M06), information from Smith and Nephew (M04, M06) including the Wound Wise manual (R02) and various other manufacturer guides, leaflets, books and charts (M08, R01, R02, R04). All of these sites had at least one resource that was no more than 2 years old.

8.1.2.5 Policies and procedures maintained

None of the 13 pharmacies documented any information collected in discussion with customers about wound care, nor did any site have any other documents or standard forms to support their wound care service (either wound care referral forms, records of the wound care treatment recommended or provided, or records of wound monitoring and review of wound healing). Four of the 11 responding pharmacies (M01, M06, M08, R01) kept patient wound care records, but did not record the outcome of that care. The remaining sites did not keep patient wound care records. The range of wound care related policies and procedures maintained by each of 13 sites are shown in Table 8.7. Few sites reported having written policies or procedures. The majority of pharmacies had policies or procedures related to the supply (stock levels) and appropriate use of a product, although these tended to be unwritten. Only 2 had procedures for monitoring wound progress, albeit unwritten. Only 5 sites had policies or procedures (mostly unwritten) related to staff and pharmacist training or maintenance of current knowledge or skills. The majority of sites had policies on referral but fewer had policies or procedures on just how to make a referral.

52

Table 8.7 Aspects of wound care policies and procedures maintained

Irrelevant None but relevant Yes, unwritten Yes, written Maintaining appropriate levels of dressings products from relevant categories

R05 M01 M03 M05 M08 M11 R01 R04 R06

R08

M04 R02*

For staff advising customers on appropriate use of all products stocked

M03 R05 M01 M04 M05 M06 M08 M11 R01 R02

R06 R08

R04

When and how to monitor wound progress

R06 M01 M03 M04 M05 M08 M11 R01 R02

R05 R08

M06 R04

Wound care training/education requirements

• For pharmacy assistants • For pharmacists

M01 M03 M05 M08 M11 R01 R05 R08

M01 M03 M04 M05 M08 M11 R01 R05

M04 R02 R06

R02 R04 R06 R08

M06 R04

M06

Maintaining current wound care knowledge & skills


M01 M03 M05 M08 M11 R01 R05 R08

M01 M03 M04 M05 M08 M11 R01 R05

M04 R02 R04 R06

R02 R04 R06 R08

M06

M06

Decision making for wound care addressing when to treat and when to refer


R08 M01 M05 R01 R05

M04 M05 R01 R05

M03 M04 M08 M11 R02 R06

M01 M03 M08 M11 R02 R04 R06 R08

M06 R04

M06

How to make a wound care referral to another practitioner

M01 M05 M11 R01 R02 R05 R08

M03 M04 M08 R04 R06

M06

Maintenance of wound care resources

R06 M01 M05 M08 M11 R01 R05 R08

M03 M04 R04 M06 R02**

* noted as point of sale software ** noted as ‘computer’

8.1.3 STAFF QUIZZES

Quizzes were returned by 20 pharmacists and 33 pharmacy assistants across 11 sites. There were 18 questions that were asked of both pharmacists and pharmacy assistants, and 6 short answer questions asked of the pharmacists. The pharmacy assistant quiz also sought information about the extent to which the assistants persuaded customers to purchase a more appropriate product, whether the assistant had had any wound care training and the assistants’ estimates of the types of wounds seen. Of the first 18 questions, the question most commonly answered incorrectly by both pharmacists and assistants related to whether a person with a 1cm sore of 1 weeks duration should be referred to a pharmacist (Table 8.8). Three pharmacy assistants and 1 pharmacist did not believe that a person using a passive dressing on a chronic ulcer should be referred, while more pharmacists than assistants did not think a child with a scald required referral to the pharmacist. Two thirds of the pharmacy assistants believed, incorrectly, that a scab was good protection for a wound. More than 20% of pharmacy assistants also responded incorrectly about the indications for film and charcoal dressings, and the frequency of dressing changes. Pharmacist scored less well than pharmacy assistants on the indication for Duoderm, the rate of moist wound healing, and the benefits of charcoal dressings. When asked short answer questions that required more detailed wound care knowledge, pharmacists indicated some product knowledge of the advanced dressing types but performed least well in questions related to more unusual dressings (Aquacel and zinc paste bandages) (Table 8.9). Pharmacists recognised factors for referring a patient to their GP, although only one identified all 4 risk factors, and one quarter of pharmacists identified more than 2 factors.

53

Table 8.8 Percentage of incorrect responses to quiz questions answered by both pharmacy assistants and pharmacists

% incorrect responses Questions on situations for automatic referral to pharmacist/seek other help, or answer true or false

Correct answer Assistant Pharmacist

A painful sore 1cm across on the shin that has been there for one week after a bump on a shopping trolley

No 66.7 60.0

A graze on the knee that is bleeding a little after coming off a skateboard

No 3.0 5.0

A lady who comes in weekly for the last several months for more Melolin for her ulcer

Yes 9.1 5.0

A child with a very painful red burn, and a small blister after being scalded by hot water spilled from a kettle – area is about 6cm x 6cm on the arm.

Yes 6.1 15.0

A middle aged man with a sore on his toes that he says is painless but looks a bit yellowish and black. He is also getting his prescription for his diabetes tablets.

Yes 0.0 0.0

A woman with a wound on her leg – she doesn’t know how it started – but it is quite painful and very red around it. She says it feels hot to touch.

Yes 0.0 5.0

Lyofoam is a foam dressing True 3.0 5.0 Film dressings, eg Opsite or Tegaderm, are good for bleeding wounds

False 27.3 5.0

Duoderm can be used on any wound False 12.1 25.0 A scab is good as it protects the wound False 66.7 15.0 Moist wounds heal faster than dry ones True 3.0 10.0 Applying local pressure can help stop minor bleeding True 0.0 0.0 Dressings with charcoal in them are for smelly wounds True 21.2 30.0 Dressings should always be changed at least once each day False 21.2 0.0 You should never use Betadine on any wound False 6.1 5.0 Hydrogels dressings (eg Intrasite or Solugel) are only good for wounds with a lot of fluid or exudate coming out of them

False 6.1 10.0

Solugel can be used on chicken pox and minor burns True 6.1 0.0 Gauze is a good dressing to use on any wound False 12.1 0.0 Some pharmacists did seek information to help answer these questions, mostly in relation to the questions about Aquacel and zinc paste bandages. Note that in Table 8.3, 10 sites did not stock Aquacel. The resources used were APP Guide or MIMS (3), lecture notes/materials from the Wound Foundation or other lecturers (Jan Rice) (3), APF (1), a nurse on staff (1) and the manufacturer (1 – although a response was not received in time). Generally, pharmacists and pharmacy assistants did well in correctly responding to these questions with overall mean scores being between 15 and 16 out of 18 (Table 8.10). Pharmacists did less well for question3 (short answers) with an average score of 6.2 out of 14 (range 2 to 12). The pharmacy assistant scores for questions 1 and 2 were positively correlated with both the pharmacists’ score for questions 1 and 2 (Pearson’s coefficient = 0.689 p=0.028 n=10) and their total score (sum of questions 1, 2 and 3) (Pearson’s coefficient = 0.617 p=0.058 n=10) (Figure 8.20). When the pharmacist and pharmacy assistant scores for questions 1 and 2 were compared, in 2 sites (R08 and M06), the pharmacy assistants scored better than the pharmacists.

54

Table 8.9 Percentage of incorrect responses to short answer quiz questions answered by pharmacists

Questions requiring a short answer Correct Answer % incorrect Diabetic 15.0 Not improving 45.0 Painful 80.0

A regular customer of your pharmacy is collecting his prescription for his gliclazide and asks for some Melolin® for a sore on his shin. On inquiry, he tells you that it has been there for about two weeks after he scratched it in the garden and doesn’t seem to be getting any better. It is still painful. He says it is about the size of a 10 cent piece and his dressing gets so wet he needs to change it at least twice a day. What would be the key factors you would consider that would indicate the need for you to refer him to his GP?

Potential for infection due to nature of injury

55.0

Calcium alginates only (1 mark) 75.0 Do sodium or calcium alginates act as a haemostatic agent? Please name one brand of this type that acts as a haemostatic agent

eg Kaltostat (1 mark) 25.0

It only absorbs exudate vertically from the wound (1 mark)

60.0 The vertical wicking properties of Aquacel mean what?

Protects the skin surrounding the wound from maceration (1 mark)

85.0

Apply principle of moist wound healing and stop scab formation (1 mark)

15.0 What makes a hydrogel a useful treatment for chickenpox?

Keeps nerve endings moist to reduce irritation (1mark)

55.0

Amount of exudate (1 mark) 35.0 What feature of a wound would influence your choice of a foam dressing instead of a hydrocolloid? Foam is more absorbent than

hydrocolloid (1 mark) 85.0

Red, superficial wound (1 mark) 95.0 What are the simple indications for using a zinc paste bandage? Wound with surrounding venous

eczema or irritation (1 mark) 90.0

Table 8.10 Quiz results for pharmacist and pharmacy assistant quizzes

Pharmacist quiz Pharmacy Assistant quiz

Site

No. pharmacist responses

Mean score for

Q1+2 Mean

score Q3

Mean % total score (Q1+2+3)

No. assistant responses

Mean score for

Q1+2

Mean % of customer persuaded

No. PAs with wound

training M01 4 15.75 6.00 67.97 1 12.00 - 0 M03 2 17.00 9.00 81.25 7 15.00 65.00 1 M04 3 17.00 7.33 76.04 3 16.33 26.00 1 M05 2 14.50 5.00 60.94 2 14.50 80.00 2 M06 1 15.00 7.00 68.75 1 17.00 60.00 1 M08 1 16.00 3.00 59.38 2 14.00 3.50 0 M11 1 13.00 4.00 53.13 1 9.00 - 0 R01 2 15.50 6.00 67.19 4 15.00 56.25 3 R02 2 17.50 8.00 79.69 3 17.00 70.00 3 R04 - - - - 3 16.00 - 0 R08 2 16.00 4.00 62.50 6 16.50 46.00 1 Overall Mean 15.95 6.20 69.22 15.36 52.25

55

Mean Q1+Q2 score pharmacists

18161412108

PA

Mea

n qu

iz s

core

Q1+

Q2

18

16

14

12

10

8

R08R02

R01

M11

M08

M06

M05

M04

M03

M01

Mean pharmacist score Q1+2+3

3228242016128

PA M

ean

quiz

sco

re Q

1+2

18

16

14

12

10

8

R08R02

R01

M11

M08

M06

M05

M04

M03

M01


3228242016128

PA M

ean

quiz

sco

re Q

1+2

18

16

14

12

10

8


3228242016128

PA M

ean

quiz

sco

re Q

1+2

18

16

14

12

10

8

R08R02

R01

M11

M08

M06

M05

M04

M03

M01

Figure 8.20 Scatterplots of pharmacy assistant quiz scores versus pharmacist scores

(questions 1+2 and sum of all three questions) showing regression line Pharmacy assistants were also asked about the percentage of wound care customers they had been able to persuade to purchase a more appropriate dressing than the one the customer had initially requested or selected. Overall, pharmacy assistants estimated they had influenced about half of the wound care customers to make a more appropriate purchase (Table 8.10), however, one site reported persuasion with 80% of wound care customers while assistants at some sites rated their persuasive powers as low (less than 30%). Twelve of the 33 responding pharmacy assistants reported having received any wound care training (Table 8.10). Some of the training was recent and some a long time ago: • Wound Wise training in the last year (2) • Other training from companies (3) – one with Smith & Nephew 4 years ago (this person

wrote that they had not been informed of or invited to attend any more recent training, despite being from a metropolitan pharmacy); one with Biersdorf in New Zealand (this person also claimed in-store, on the job training over the last year); one with Biersdorf about 7 years ago

• A Wound management course (including the Victorian College of Pharmacy course) (3) (about 2 years ago in 1 case)

• First Aid Certificate (3) • Pharmacy Guild of Australia product knowledge booklet on “Wound Care” read about 12

months ago (1) • Other, unspecified wound training (a long time ago) (1) Wound care training influenced the assistants score in the pharmacy quiz (p=0.086) and to a lesser extent, their estimates of the percentage of customers persuaded to purchase a more appropriate wound product (p=0.153) (Figure 8.21).

56

1220N =

Any wound care training

YesNo

PA

qui

z sc

ore

Q1+

Q2

18

16

14

12

10

8

1113N =

Any wound care training

YesNo

% c

usto

mer

s pe

rsua

ded

120

100

80

60

40

20

0

-20

Figure 8.21 Boxplot comparing pharmacy assistant wound care training status and

pharmacy assistant quiz score and percentage of wound care customers persuaded to purchase a more appropriate product

From the small number of pharmacists whose training status could be determined from the profile, training had no effect on quiz performance (Figure 8.25).

55N =

P'cist trained in last 2 years per profile

TrainingNo training

Tota

l qui

z sc

ore

out o

f 32

28

26

24

22

20

18

16

Figure 8.22 Boxplot comparing pharmacist wound care training status and quiz

The number of assistants with wound care training as reported by the proprietor/manager varied from that reported by assistants completing the quiz. In some cases, the proprietor reported more staff with training and in others more assistants reported being trained than the proprietor reported (Table 8.11). Only the mean total pharmacist quiz score (Figure 8.23) and mean score for the open-ended questions per site were associated with the proprietors’ ratings of overall service quality (Spearman’s rho=0.717 p=0.020 n=10 and rho=0.654 p=0.040 n=10 respectively) and the service level provided (rho=0.681 p=0.030 n=10 and rho=0.716 p=0.020 n=10 respectively). Pharmacist quiz scores were not related to ratings for space and facilities or the wound care display. The pharmacy assistant quiz scores were not related to proprietors’ quality assessments, although there was a trend between increasing mean pharmacy assistant quiz scores and overall quality ratings (rho=0.510 p=0.109 n=11).

57

Table 8.11 Number of trained pharmacy assistants as reported by the proprietor and the assistants

Site No. of assistants trained in wound

care per profile No. assistants trained in wound care

per quiz Assistants employed

M01 5 0 of 1 respondent trained 1 M03 2 1 of 7 respondents trained - M04 3 1 of 3 respondents trained 4 M05 2 2 of 2 respondents trained 6 M06 3 1 of 1 respondent trained 3 M08 0 0 of 2 respondents trained 3 M11 1 0 of 1 respondent trained 2 R01 2 3 of 4 respondents trained 6 R02 2 3 of 3 respondents trained 5 R04 - 0 of 3 respondents trained 6 R05 1 - 7 R06 4 - 5 R07 - - 5 R08 0 1 of 6 respondents trained 6

Mean total pharmacist quiz score

28262422201816

Pro

file

Ove

rall

qual

ity ra

ting

120

100

80

60

40

20

R08

R02

R01M11

M08

M06

M05

M04

M03

M01

Mean total pharmacist quiz score

28262422201816

Pro

file

Ove

rall

qual

ity ra

ting

120

100

80

60

40

20

R08

R02

R01M11

M08

M06

M05

M04

M03

M01

Mean P'cist open ended score

1098765432

Pro

file

Ove

rall

qual

ity ra

ting

120

100

80

60

40

20

R08

R02

R01M11

M08

M06

M05

M04

M03

M01

Mean P'cist open ended score

1098765432

Pro

file

Ove

rall

qual

ity ra

ting

120

100

80

60

40

20

R08

R02

R01M11

M08

M06

M05

M04

M03

M01

Figure 8.23 Scatterplot of mean pharmacist quiz scores versus proprietor’s overall quality rating

The pharmacy assistant quiz also sought information on the assistants’ estimates of the percentage of wound care customers with various types of wounds (Table 8.12). Assistants from 2 sites (M11 and R04) were not prepared to make these estimates, despite responding to the quiz. Overall, pharmacy assistants estimated that more than twice as many wound care customers had cuts and grazes (40%) than those with burns (15%), leg ulcers/pressure sores (17%) or stitches/surgical wounds (18%). The percentage estimate for cuts and grazes ranged from 21% to 60%. For burns this range was 3% to 40%, for leg ulcers/pressure sores (0 to 30%), for stitches/surgical wounds (6% to 32%) and for people making a purchase for future use 0 to 57%.

58

Table 8.12 Pharmacy assistant estimates of the percentage of wound care customers with various types of wounds

Mean % of wound care customers Site None for

future use Cuts & grazes

Burns Leg ulcers or pressure sores


Other wounds

M01 0.00 30.00 40.00 0.00 30.00 0.00 M03 0.83 32.50 20.00 27.50 17.50 1.00 M04 0.00 60.00 10.00 8.00 17.00 0.33 M05 10.00 30.00 20.00 8.00 32.00 0.00 M06 17.00 21.00 14.00 24.00 24.00 0.00 M08 57.50 27.50 3.00 6.50 5.50 0.00 R01 0.00 50.00 17.50 11.25 21.25 0.00 R02 0.00 30.00 20.00 30.00 15.00 5.00 R08 5.83 46.67 8.33 16.67 19.17 3.33 Overall mean 7.00 40.04 15.19 17.37 18.44 1.64

8.1.4 STOCK ON HAND

The quality of the data recording of stock on hand was varied, making detailed comparisons difficult. Some sites (M06, R01, R04, R08) misclassified dressings despite being provided with a table indicating the categories to which products belonged, while in others the number of single dressings was not specified or only estimated (particularly for passive and first aid dressings). R05 and R07 did not complete the stock holdings data collection form, while M05 did not complete the form but sent a computer POS printout of the section. The data from R04 was suspected to be incomplete because it did not include passive dressings or simple first aid (known to be stocked). The product types kept in each class were counted for each pharmacy and summed across the 12 sites providing stock data. The items most commonly stocked in each class are shown in Table 8.13. The most commonly stocked category of dressings was the passive dressings, followed by film and hydrocolloid dressings. The single most common products stocked were Melolin (10 reported but probably 11 of 12 sites), Lyofoam and Solugel (10 of 12 sites each). The Duoderm range included Duoderm, Duoderm extra thin, CGF and paste but 10 sites carried at least 1 Duoderm product. Kaltostat included sheets and ropes of dressing and was stocked by 9 sites. One site (M06) stocked a hydrocolloid dressing (Hydroheal) that had been discontinued for some time. Bandaid strips were the most commonly stocked line of simple first aid products.

59

Table 8.13 Overall frequency of products stocked in descending order within dressing type category

Dressing type (No. total responses/ category)

Product stocked No. of sites stocking product

Product stocked No. of sites stocking product

Tegaderm 9 Cutifilm 3 Opsite 6 Hansaplast Aqua Protect 3 Opsite flexifix 5 Polyskin 1 Opsite post-op 5 Tegaderm island 1

Film dressings (n=38)

Cutifilm Plus 4 Clean seal 1 Lyofoam 10 Lyofoam extra 2 Allevyn 7 Avance 1

Foam dressings (n=25)

Allevyn adhesive 5 Duoderm range 16 Curaderm 1 Comfeel range 6 Hydroheal Hydrocolloid 1

Hydrocolloid dressings (n=27)

Replicare Ultra 3 Solugel 10 Duodermgel 2 Intrasite 5 Bandaid Healing Gel 1 Purilon Gel 3 Secondskin 1

Hydrogels (n=25)

Solosite 3 Cutinova Thin 5 Biatain 2 Cutinova Hydro 4 Cutinova Cavity or foam 1

Polymer dressings (n=16)

Polymem 3 Polymax 1 Kaltostat 11 Polymem calcium 1 Seasorb range 2 Restore 1

Alginates (n=17)

Sorbsan 2 Hydrofibre (n=6) Aquacel 6 Cadexomer Iodine (n=8) Iodosorb 7 Iodoflex 1

Steripaste 5 ZipZoc 3 Zinc paste bandages (n=13) Viscopate 3 Gelocast 2

Melolin 10 Adaptic 2 Jelonet 8 Airstrip 2 Bactigras 7 Unitulle 2 Gauze 7 Aquaphor 1 Primapore 7 Cotton wool 1 Combine 5 Exu-dry 1 Cutilin 5 Hansapor 1

Passive dressings (n=64)

Cutiplast 4 Telfa 1 Any Bandaid strips 8 Any Elastoplast 5 Simple first aid

(n=24) Any Nexcare strips 6 Any Hansaplast strips 5 The number of different dressing types carried in each dressing category at each site is shown in Table 8.14. The most commonly stocked items overall were passive dressings followed by film dressings representing 25 and 14% of dressing products stocked, respectively. Excluding R04, whose stock report was incomplete, and the benchmarking site (M01), passive dressings represented between 17 and 43% of dressing products stocked. At the benchmark site, stock was kept across a range of categories. The number of individual dressings stocked could not be reliably compared for all sites because of differences in how the information was reported in that some sites reported pack whereas others counted individual dressings, and just which was which could not always be determined.

60

Table 8.14 Number of products stocked in each product category per site and percentage of total number of different products stocked

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04* R06 R08 Overall Product category N % N % N % N % N % N % N % N % N % N % N % N % N %

Films 2 7.4 2 6.7 5 14.7 3 18.8 3 20.0 3 15.8 2 13.3 3 13.6 3 17.6 3 23.1 5 13.2 4 17.4 38 14.1 Foams 3 11.1 4 13.3 2 5.9 1 6.3 1 6.7 2 10.5 1 6.7 2 9.1 1 5.9 2 15.4 3 7.9 3 13.0 25 9.3 Hydrocolloids 4 14.8 2 6.7 5 14.7 1 6.3 1 6.7 2 10.5 2 13.3 2 9.1 2 11.8 3 23.1 3 7.9 0 0.0 27 10.0 Hydrogels 5 18.5 3 10.0 4 11.8 0 0.0 1 6.7 2 10.5 1 6.7 2 9.1 1 5.9 1 7.7 3 7.9 2 8.7 25 9.3 Polymers 3 11.1 2 6.7 3 8.8 0 0.0 0 0.0 0 0.0 1 6.7 3 13.6 2 11.8 1 7.7 3 7.9 0 0.0 18 6.7 Alginates 4 14.8 2 6.7 2 5.9 0 0.0 1 6.7 0 0.0 1 6.7 2 9.1 1 5.9 1 7.7 1 2.6 2 8.7 17 6.3 Hydrofibres 0 0.0 2 6.7 1 2.9 0 0.0 1 6.7 0 0.0 1 6.7 0 0.0 0 0.0 1 7.7 0 0.0 0 0.0 6 2.2 Cadexomer iodine 2 7.4 2 6.7 2 5.9 1 6.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 2.6 0 0.0 8 3.0 Zinc Paste Bandages 2 7.4 4 13.3 3 8.8 0 0.0 0 0.0 0 0.0 0 0.0 1 4.5 0 0.0 0 0.0 3 7.9 0 0.0 13 4.8 Passive dressings 2 7.4 6 20.0 6 17.6 7 43.8 5 33.3 7 36.8 4 26.7 4 18.2 4 23.5 1 7.7 13 34.2 9 39.1 68 25.3 First Aid 0 0.0 1 3.3 1 2.9 3 18.8 2 13.3 3 15.8 2 13.3 3 13.6 3 17.6 0 0.0 3 7.9 3 13.0 24 8.9 Total No. different products 27 30 34 16 15 19 15 22 17 13 38 23 269 N= No. product types in each category at each site and overall %= Percentage of total number of different products/site and overall * possible incomplete data for passive dressings and simple first aid Note: different sizes of the same product were not counted separately, rather different product types were counted e.g. Tegaderm and Tegaderm Island dressing were counted as two product types because they had different uses

61

Of more interest however, was the extent to which essentially equivalent products were stocked by the same site (antiseptic tulle gras (Bactigras) was considered to be essentially the same as tulle gras). Three sites (M01, M03 and M04) had community nursing contracts which might account for the apparent stock duplication but the duplicated products carried by other sites tended to be passive dressings (16 duplicates/triplicates) and film dressings (13 duplicates/triplicates) (Table 8.15).

Table 8.15 Therapeutic duplication among the dressing types stocked

Dressing category Equivalent products stocked (irrespective of product size) Films Tegaderm - Opsite Hydrocolloid Comfeel Ulcer – Duoderm Extra thin; Comfeel Plus Ulcer - Duoderm

M01

Passive dressing Cutilin - Melolin Films Tegaderm - Opsite Hydrocolloid Duoderm - Replicare

M03

Passive dressing Jelonet - Bactigras Films Tegaderm – Opsite – Cutifilm; Cutifilm plus – Tegaderm Island Hydrocolloid Comfeel – Duoderm – Replicare - Curaderm

M04

Passive dressing Cutilin - Melolin M05 Passive dressing Jelonet - Bactigras

Films Tegaderm – Opsite flexigrid – flexigrid shapes M06 Passive dressing Cutilin – Melolin; Cutiplast - Primapore

M08 Passive dressing Jelonet - Bactigras; Airstrip - Primapore M11 Passive dressing Jelonet - Bactigras

Films Tegaderm – Opsite – Cutifilm R01 Passive dressing Jelonet – Bactigras - Adaptic

R02 Films Nexcare Tegaderm – Opsite Post-op; Opsite Flexifix - Cleanseals Films Tegaderm - Opsite R04 Hydrocolloid Duoderm - Comfeel Films Tegaderm – Opsite – Cutifilm; Cutifilm plus – Opsite Post-op Hydrocolloid Comfeel – Duoderm – Replicare

R06

Passive dressing Adaptic - Jelonet – Bactigras - Unitulle; Airstrip – Primapore – Cutiplast - Hansapor; Cutilin – Melolin

Films Tegaderm – Opsite flexifix; Opsite post-op – Cutifilm plus Hydrocolloid Duoderm - Comfeel Hydrogels Solugel – Bandaid Healing gel

R08

Passive dressing Jelonet - Bactigras; Melolin – Cutilin – Telfa; Cutiplast - Primapore Compression hosiery was stocked by 8 sites with 5 keeping more than one brand (M01, M03, M04, M08, R01). Where sites did not stock compression hosiery (M11, M06, R02, M05–missing), these products could be ordered upon request. Brands stocked were: • Jobst (4 sites) • Ted (3 sites) • Scholl (2 sites) • Venosan (2 sites) • Biomet (1 site) • Oapl (1 site) • Unspecified brand/s compression stockings/socks (1 site) Information on the presence of a trained fitter of compression hosiery was not sought.

62

8.1.4.1 Pharmacy reported stock holding versus audit stock holding

The current stock holdings form was completed some time after the stock holdings were recorded at audit. Overall, there were 15 stock range differences between the audit and the stock holdings reported by the sites (compare Table 8.16 with Table 8.3). Still only 2 of 13 pharmacies stocked at least one produce from each wound care category, however, M01 no longer had stock of hydrofibre dressings and M03 had added cadexomer iodine dressings since the audit. Other out of stocks since the audit were hydrogels for M05, polymers and zinc paste bandages for M06, and zinc paste bandages for R02 and R04. Note that none of these products were reported as ‘sold’ in the 2 weeks of the customer log (Table 8.24). M06, M08 and M11 reported stock of foam dressings that were not seen at audit. Other additions were cadexomer iodine for M05, hydrofibres for M06, zinc paste bandages for R01 alginate dressings for R06 and hydrogels for R08.

Table 8.16 Stock range and stock level score for each product category for each site from current stock holdings form

Site Stock range score / Stock level score for each dressing product category Films Foams Hydro-

colloid Hydr-ogels

Poly-mer

Algin-ates

Hydr-ofibre

Cadexomer Iodine

Zinc Paste b’age

Pass-ive

First aid

Sum of stock range score

Sum of stock level score

M01 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 0 / 0 4 / 4 6 / 18 6 / 18 6 / 18 54 162 M03 6 / 18 6 / 18 6 / 18 6 / 18 4 / 12 4 / 12 4 / 12 4 / 4 6 / 18 6 / 18 6 / 18 54 162 M04 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 6 / 18 4 / 12 4 / 12 6 / 12 6 / 18 4 / 8 56 158 M05 6 / 12 2 / 2 2 / 4 0 / 0 0 / 0 0 / 0 0 / 0 2 / 2 0 / 0 6 / 18 6 / 18 22 54 M06 6 / 18 2 / 2 2 / 4 2 / 2 0 / 0 2 / 2 2 / 4 0 / 0 0 / 0 6 / 18 6 / 18 28 68 M08 6 / 12 6 / 6 4 / 8 6 / 12 0 / 0 0 / 0 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 34 74 M11 6 / 12 2 / 2 4 / 12 4 / 4 4 / 12 4 / 8 2 / 6 0 / 0 0 / 0 6 / 18 6 / 18 38 92 R01 6 / 18 6 / 18 4 / 8 6 / 18 4 / 8 6 / 6 0 / 0 0 / 0 2 / 2 6 / 12 6 / 12 46 102 R02 6 / 18 2 / 2 6 / 18 4 / 8 4 / 12 4 / 4 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 38 98 R04 6 / 18 6 / 6 6 / 18 2 / 2 2 / 6 2 / 2 2 / 4 0 / 0 0 / 0 6 / 18 6 / 18 38 92 R05 R06 6 / 18 6 / 18 6 / 18 6 / 12 4 / 8 4 / 8 0 / 0 4 / 12 6 / 6 6 / 18 6 / 18 50 124 R07 R08 6 / 18 6 / 18 6 / 18 6 / 18 0 / 0 6 / 12 0 / 0 0 / 0 0 / 0 6 / 18 6 / 18 42 120

8.1.4.2 Stock holdings versus turnover from wound care

Higher stock levels, particularly of advanced, or more interactive dressings, as indicated at audit and in the current stock holding reported by pharmacies were generally associated with a higher percentage of turnover from wound care (Table 8.17). Differences between the audit and stocktake correlations were due to changes in stock levels between the two assessments. For example, for film dressings, stock scores in 2 lower turnover pharmacies were lower at stocktake than at audit, changing the correlation, and for 5 sites, the stock scores for hydrocolloid dressings increased from audit to stocktake. The stock scores for foam, polymers and zinc paste bandages, and the overall stock range and total stock scores were positively correlated with the percentage of turnover from wound care at both times. Interestingly, while there was no variability in the stock scores for passive dressings and first aid dressings at audit, at stocktake, the correlation coefficients for these product categories were negative although small and not significant. This suggests that as stock score increased, the proportion of turnover from wound care decreased.

63

Table 8.17 Correlations between stock levels and percentage of turnover from wound care

Proportion of turnover related to W/C Spearman’s correlation coefficient

Stock scores Audit n=11 Stocktake n=10 Film stock score (brands x sizes x units) 0.318 P=0.341 0.715 P=0.020 Foam stock score (brands x sizes x units) 0.708 P=0.015 0.591 P=0.072 Hydrocolloid stock score (brands x sizes x units) 0.669 P=0.024 0.497 P=0.144 Hydrogels stock score (brands x sizes x units) 0.377 P=0.253 0.732 P=0.016 Polymer stock score (brands x sizes x units) 0.670 P=0.024 0.581 P=0.078 Hydrofibre stock score (brands x sizes x units) 0.671 P=0.024 0.348 P=0.325 Cadexomer Iodine stock score (brands x sizes x units) 0.424 P=0.194 0.323 P=0.362 Zinc paste bandages stock score (brands x sizes x units) 0.653 P=0.029 0.732 P=0.016 Passive dressing stock score (brands x sizes x units) - - -0.061 P=0.868 First aid stock score (brands x sizes x units) - - -0.289 P=0.417 Stock range score (sum of brands x sizes) 0.753 P=0.007 0.693 P=0.026 Total dressing stock score (sum of brands x sizes x units) 0.731 P=0.011 0.731 P=0.016

8.1.5 SALES/PURCHASE DATA

Only six pharmacies provided sales or purchase history data. Two sites did not fill out the form by dressing category class. One of these sites sent in a POS printout while the other who could not compile sales data because of a change in the POS system, sent a purchase history report (possibly from their wholesaler). Four sites provided sales data from their POS, one site (mentioned above) provided purchase data while another site used a combination of sales and purchase data to compile the report. Five of the six pharmacies had both usable stock data and sales/purchase history data. The percentage of simple first aid products sold or purchased ranged from 1.5% to over 60% (Table 8.18). In 3 of the 5 sites however, sales of passive dressings were the highest category. Sales of film dressings were about twice as high in the two sites with community nursing contracts compared to R01-R08. In comparing Table 8.18 with Table 8.14, it can be seen that for 4 of the 5 sites, the percentage of sales made up by passive dressings exceeded the percentage of stock held that were passive dressings. R08 held more passive dressings than were sold, possibly related to the 9 different types of passive dressings stocked. For the majority of sites, the proportion of stock held for the more advanced dressing categories generally exceed the percentage of sales in these categories, although stock holdings and sales more closely matched for M04. Sites R01, R02 and to a lesser extent R08 has a good match between sales and stock for the hydrogels. Since only a small number of sites provided sales/purchases data, this could not be meaningfully compared to percentage turnover from wound care products but this information is in the last line of Table 8.18. As an alternative, sales as per the customer log were compared to turnover are shown later (Figure 8.24).

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Table 8.18 Average percentage of total wound care sales per quarter for each dressing category

Average % of total dressing units sold overall and excluding first aid products M01 M04 R01 R02 R08

Dressing category

Overall Exclude 1st aid Overall

Exclude 1st aid Overall



Exclude 1st aid

Film 21.3 21.6 30.0 31.0 13.4 16.3 11.4 17.2 6.0 15.5 Foams 9.1 9.2 10.7 11.1 0.7 0.8 0.3 0.4 1.5 3.9 Hydrocolloids 5.0 5.1 10.1 10.4 1.1 1.3 1.3 2.2 1.8 4.6 Hydrogels 1.6 1.7 2.8 2.9 6.8 8.2 7.8 11.6 2.8 7.3 Polymers 1.1 1.2 8.8 9.0 1.9 2.2 1.3 1.8 0.0 0.0 Alginates 1.7 1.7 3.8 3.9 1.4 1.6 0.0 0.0 1.8 4.5 Hydrofibres 0.0 0.0 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0 Cadexomer iodine 2.5 2.5 2.7 2.7 0.0 0.0 0.0 0.0 0.0 0.0 Zinc paste bandage 2.6 2.7 3.4 3.5 1.0 1.2 0.3 0.4 0.0 0.0 Passive dressings 53.6 54.4 24.5 25.3 56.9 68.2 44.0 66.4 25.0 64.3 Simple 1st aid 1.5 3.0 17.0 33.7 61.3 % turnover >5% 2-3% 1-2% 1-2%

8.1.6 CUSTOMER TELEPHONE SURVEY

Only 15 customers were recruited by 7 pharmacies (Table 8.19), although 2 of these customers did not meet the eligibility criterion of having a current wound (one from R02 was treating scaring from surgery 12 months previously, and the other from M08, was getting a dressing for future use). As indicated in the post pilot interviews (Appendix C), pharmacies were selective in the customers they approached to recruit, rather than recruiting consecutive customers as they were instructed to do. Nine customers completed the survey (Table 8.19). Since there were so few responses, the responses from the 2 customers without a current wound were included. Five customers could not be contacted by phone despite 5 separate attempts and one customer withdrew. Four of the 15 participants were male and of these only one completed a survey.

Table 8.19 Recruitment and responses to the customer survey

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08 Total No. recruited 1 1 2 1 3 6 1 15 No. surveyed 0 1 1 1 2 3 1 9

Of those that responded all but one patient said that they used this pharmacy almost always (89%) while only one indicated that it was not their usual pharmacy and that the pharmacy was visited only very occasionally. For the majority (66%), the wounds for which they were seeking treatment were on the extremities (hands, arms, feet, legs). Other customers had wounds at the groin, under the breast and on the chest. Wounds ranged in origin (2 x burns, 1 friction wound, 1 x leg ulcers, 2 x cuts and scratches, 3 x post-operative wounds i.e. hernia repair, lancing of an abscess, bypass surgery). The average approximate size of initial wounds was 12 cm2 although the median size was 5cm2. Two wounds (a burn and a graze) were more than 20cm2. Several respondents indicated that at the time of the survey, the wound size had reduced from the

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initial size. Most (78%) of the wounds were acute in nature and had not been treated for more than three weeks, although there was one patients with a persisting leg ulcer. Another customer was using scar reduction treatments 12 months after cardiac surgery. The majority of products supplied to customers were passive dressings and associated tapes and bandages (12 of 18 products) (Table 8.21). Customers’ choice of product was influenced by doctors, the hospital or a nurse (44%) and by pharmacists (44%) and assistants (33%). In all cases the pharmacy assistant was involved in the product purchase and 78% of the time the assistant was reported to ask something about the wound. Pharmacist involvement occurred 78% of the time and of these interactions the pharmacist was reported to ask something about the wound 71% of the time. Most customers reported changing the dressing at least daily at some point in the healing process. At the time of the survey, 2 customers with current wounds were changing their dressing daily (both using passive dressings). In only 55% of cases did the customer recall anyone from the pharmacy giving advice on use of the dressings. These instructions were oral although one pharmacy (M04) gave written information as well. Only one of the 9 patients (M04) had been told what to expect as the wound healed. Six of the patients had received prior information about dressing their wound. (4 doctor, 1 hospital, 1 nurse). Only 4 patients responded to the question about who gave the most useful advice, the pharmacy or the other source. Two couldn’t decide if the information the pharmacy gave was any better than their previous knowledge (M03, R02) while the third clearly rated the pharmacist better (R02) and the fourth rated the doctor’s advice as superior (R02). The majority of customers rated the pharmacies as excellent in meeting their overall wound care needs (5 of 9) (Table 8.20). All but 3 customers rated the level of help they had received from the staff as excellent and most had no concerns over waiting time for service.

Table 8.20 Ratings of service quality (from poor, fair, good, very good and excellent)

Site Wound Level of help received from staff

Amount of waiting time for wound care service

Overall, how wound care needs met

M03 Surgical wound 3 wks ago Very good Very good Very good M04 Burn 2 wks ago Excellent Excellent Excellent M08 Nil - for future scratches/cuts Excellent Very good Very good R01 Leg ulcer >4mths Excellent Excellent Very good R01 Surgically drained abscess Excellent Excellent Excellent R02 Friction wound 2 days ago Excellent Excellent Excellent R02 Large graze 16 days ago Excellent Excellent Excellent R02 Scar for reduction Very good Excellent Excellent R08 Burn on child Good Good Good Three patients offered extra information about further improving the pharmacy’s service. The first (M03) was that the product would have been better if it was available in larger sized sheets and also that while the pharmacy spoke about dressing the wound, it would have been helpful to have advice on protecting the clothes. The second patient (R02) would have liked to have known about the product they were using sooner. The third (R08) received verbal instructions but would also have like a brochure or written instructions for later reference.

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Table 8.21 Products provided for each customer, their interactions with staff and frequency of dressing change

Site Wound Products obtained How product chosen? Staff involved in purchase

Information about wound sought?

How often dressing changed

M03 Surgical wound 3 wks ago

2 passive & 1 film dressing Same as sent home from hospital

Assistant Yes Pharmacist No

Yes No

1st wk daily, reducing to every 2nd day

M04 Burn 2 wks ago Hydrogel Pharmacist recommended Assistant Yes Pharmacist Yes

Yes Yes

Daily at 1st, now every 2nd day

M08 Nil but for future scratches/cuts

Passive dressing Assistant recommended Assistant Yes Pharmacist Yes

No No

Change every day

R01 Leg ulcer >4mths Many different ones but uncovered at present

District nurse Assistant Yes Pharmacist Yes

No No

Every 2nd day as per Nr

R01 Surgically drained abscess

Sterile gauze & tape Pharmacist recommended Assistant Yes Pharmacist Yes

Yes Yes

Packed and drained daily or more often if too much exudate

R02 Friction wound 2 days ago*

Betadine, passive dressing & tape + skin wipe

Assistant & pharmacist recommended

Assistant Yes Pharmacist Yes

Yes Yes

Changed twice a day; Betadine not left on more than 5 mins

R02 Large graze/scrape 16 days ago**

Silvazine cream & pad/passive dressing + tube bandage

Recommended by doctor & pharmacist

Assistant Yes Pharmacist Yes

Yes Yes

Once daily

R02 Scar for reduction Cicacare Recommended by doctor Assistant Yes Pharmacist Yes

Yes Yes

Daily

R08 Burn on child Picrate dressing, gauze bandage + wide tape

Assistant recommended Assistant Yes Pharmacist No

Yes No

Keep on for 3 days then leave uncovered

* surgical stocking post knee reconstruction rubbed big toes, Savalon & Melolin initially applied + penicillin from doctor. Pharmacist changed antiseptic and tape for Melolin for a tape that did not cause problems ** Customer bandaged own leg but when pharmacist saw wound when delivering medicines to her home, he advised customer to see her doctor

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8.1.7 CUSTOMER LOG

The customer logs contained records for 197 customers seeking wound care and first aid. Of these, 2 did not have wounds (treating a wart, treating nappy rash) while no information about wound type was recorded for a further 2. For the remaining 193 customer entries, 15 were seeking products for sports, sprain or strain reasons and a further 26 wound/first aid entries were recorded after the 2 week data collection window was finished (see Table 8.22).

Table 8.22 Number of customers logged for each pharmacy

Site No. customers logged in 2 weeks

Number with wounds (exclude sprains/strains /sports related injuries) in 2 wks

Additional customers logged

M01 16 15 3 M03 5*† 5* M04 24 24 M05 9 6 M06 14 14 15 M08 3 2 1 R01 11 11 1 R02 5* 5* R04 12* 11* R05 21* 17* R06 9 7 6 R07 19 16 3 R08 19 19 3

* assumed to be 2 weeks since log entries not dated † Likely to be under-reported since at telephone interview, the pharmacist estimated that there were generally about 2 wound care customers/day. The remaining 152 customers had 153 reasons for purchasing wound or first aid products. For the 2 week period, products were mainly purchased for cuts and grazes, followed by surgical wounds and stitches (Table 8.23). The overall pattern of reasons for purchases did not change markedly when all wound care log records (not sports etc) were included. There were differences, however, in the pattern between the various pharmacies for the 2 week period of the customer log reporting. The pattern for a pharmacy also changed slightly when the wound log was kept for a longer period of time (records marked with * in Table 8.23).

Table 8.23 Reasons for wound/care first aid purchase from the customer log for each pharmacy in a 2 week window

% of wound care customers seen in 2 weeks Site None (for

future use) Cuts and grazes

Burns Leg ulcer/ pressure sore

Stitches/ surgical wound

Other wound type

Don't know

M01 26.7 33.3 13.3 6.7 6.7 13.3 M01* 33.3 27.8 11.1 11.1 5.6 11.1 M03 20.0 20.0 60.0 M04 37.5 20.8 20.8 12.5 8.3 M05 50.0 16.7 33.3 M06 26.7 26.7 20.0 6.7 6.7 13.3 M06* 20.0 26.7 23.3 10.0 6.7 13.3 M08 50.0 50 M08* 33.3 33.3 R01 9.1 9.1 9.1 36.4 18.2 18.2 R01* 8.3 8.3 8.3 41.7 16.7 16.7

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Table 8.23 continued % of wound care customers seen in 2 weeks Site None (for




Other wound type

Don't know

R02 50.0 16.7 33.3 R04 25.0 16.7 25.0 16.7 8.3 8.3 R05 64.7 11.8 23.5 R06 14.3 57.1 14.3 14.3 R06* 10.0 60.0 10.0 20.0 R07 18.8 31.3 12.5 6.3 18.8 6.3 6.3 R07* 16.7 27.8 11.1 5.6 22.2 5.6 11.1 R08 5.9 29.4 5.9 11.8 29.4 5.9 11.8 R08* 5.0 30.0 5.0 20.0 25.0 5.0 10.0 Overall 5.9 35.3 15.0 10.5 19.0 7.8 6.5 Overall* 6.1 34.8 14.9 12.2 18.2 7.7 6.1

* including the wounds reported after the 2 week window Overall, 26% of products sold for first aid or wound care purposes in a 2 week period were for passive dressings, while 17% were tapes and bandages (that might be required to keep passive dressings in place) (Table 8.24). When all transactions recorded on the log were included (including sports-related purchases), proportions of passive dressings and tapes and bandages were 24% and 21% respectively. The range of wound care products sold varied markedly between pharmacies. One site sold only passive dressings, simple first aid and tapes and bandages, while another site had sold dressings in every class except simple first aid.

Table 8.24 Products sold as recorded on the customer log

% of total dressings sold in 2 weeks/site excluding sports related purposes Site Algin-

ates Cadex-omer iodine

Films Foams Hydro-colloids

Hydro-gels

Other dressing-related products

Passive dress-ings

Polymer dress-ings

Scar reduct-ion


Tapes & band-ages

M01 8.3 4.2 4.2 16.7 29.2 16.7 20.8 M03 9.1 9.1 9.1 63.6 9.1 M04 2.8 5.6 16.7 5.6 5.6 5.6 5.6 19.4 11.1 5.6 16.7 M05 10.0 30.0 40.0 20.0 M06 21.9 3.1 15.6 21.9 3.1 21.9 12.5 M08 33.3 33.3 33.3 R01 6.3 12.5 12.5 12.5 12.5 37.5 6.3 R02 27.3 18.2 18.2 9.1 9.1 18.2 R04 25.0 62.5 12.5 R05 11.1 22.2 25.9 11.1 29.6 R06 22.2 22.2 11.1 11.1 33.3 R07 5.6 11.1 5.6 16.7 27.8 33.3 R08 19.2 3.8 11.5 53.8 11.5 Total 1.3 1.7 15.1 2.5 2.5 7.9 10.5 25.9 2.1 1.3 12.1 17.2

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Table 8.24 continued % of total dressings sold as recorded in customer log including sports related purposes Site Algin-



Hydro-gels


Passive dress-ings

Polymer dress-ings

Scar reduct-ion


Tapes & band-ages

M01 7.1 3.6 3.6 3.6 17.9 25.0 14.3 25.0 M03 9.1 9.1 9.1 63.6 9.1 M04 2.8 5.6 16.7 5.6 5.6 5.6 5.6 19.4 11.1 5.6 16.7 M05 7.7 23.1 30.8 38.5 M06 22.0 1.7 1.7 18.6 18.6 6.8 22.0 8.5 M08 40.0 40.0 20.0 R01 5.6 16.7 11.1 11.1 11.1 38.9 5.6 R02 27.3 18.2 18.2 9.1 9.1 18.2 R04 25.0 62.5 12.5 R05 9.1 24.2 21.2 9.1 36.4 R06 10.5 10.5 10.5 5.3 26.3 36.8 R07 4.5 9.1 4.5 18.2 22.7 40.9 R08 15.6 3.1 9.4 59.4 12.5 Total 1.0 1.3 14.2 2.3 2.6 8.3 10.6 23.8 1.7 1.0 12.9 20.5 Other dressing-related products were predominantly antiseptic/anti-infective products (21 of 32); other items were dressing packs/eye pads/finger stall/alcohol swab (6), ice pack (1), saline (2), analgesic topical product (2). The relationship between the percentage of wound care products sold in the 2 weeks of the log that were not passive or first aid dressings, tapes or bandages or other dressing related products was compared to the proportion of turnover from wound care (Figure 8.24). As the proportion of more advance dressings sold increased, the proportion of turnover from wound care increased (Spearman’s rho=0.615 n=10 p=0.059 for all cases and rho= 0.754 n=9 p=0.019 when M03 was excluded (because of suspected incomplete customer log)).

% products sold not basic dressings

% tu

rnov

er fr

om w

ound

car

e

1009080706050403020100

-10

>5%

4-5%

3-4%

2-3%

1-2%

<1%

R08

R06R05

R01

M08

M06

M05

M04

M03

M01

1009080706050403020100

-10

>5%

4-5%

3-4%

2-3%

1-2%

<1%

R08

R06R05

R01

M08

M06

M05

M04

M03

M01

% product sold not basic dressings

1009080706050403020100

-10

Pro

file

Ove

rall

Qua

lity

ratin

g

120

100

80

60

40

20

0

R08 R06

R05

R04 R02

R01

M08

M06

M05

M04

M03

M01

A B

Figure 8.24 Percentage of wound care products that were not passive or first aid

dressings, tapes or bandages or other dressing related products sold in 2 weeks per log versus A. the proportion of turnover from wound care (showing line of identity) and B. the proprietor assessment of overall service quality

70

Where pharmacies sold a greater percentage of non-basic dressings, the proprietor’s assessment of overall service quality was higher (rho=0.606 p=0.037 n=12) (Figure 8.24), however the proprietors gave a lower rating for the extent to which space and facility needs were met (rho=-0.644 p=0.024 n=12). Staff were asked to indicate whether the customer’s choice of product was influence or even changed by the staff member. For customer log entries in the 2 week period, 164 entries recorded this data. Customer choice was reported to be influenced in 103 cases (62.8%), and changed in 19 cases (11.6%) (in 15 cases, both influencing and changing choice were reported). In 26 of 129 cases (20.2%), the customer was referred on and in 60 of 158 cases (38.0%), the pharmacist was asked. For all customer log entries for which this data was recorded (194 customers), the customers choice was reported to be influenced in 119 cases, changed in 20 cases (in 16 cases both influencing and changing choice were reported) while for 64 of 174 customers, the pharmacist was asked (in 9 cases, the pharmacist served the customer) and 29 of 158 customers were referred on. The service patterns again varied between sites (Table 8.25). On average, staff reported that 61% of customers had had their choice influenced by the staff but estimates ranged from 0 to 93% (one site reporting 100% influence related to only 5 transactions, where 14 transactions might have been expected). Overall, for 10% of transactions, a change in customer choice was reported, while on average, the pharmacist was consulted for 36% of transaction, and customers were referred on in an average of 16% of cases. As the number of trained pharmacy assistants reported by the proprietor increased, the percentage of customers whose choice was influenced increased (rho=0.711 n=11 p=0.014) but consulting the pharmacist and referral was not related to assistant training.

Table 8.25 Interactions with customers, consultation with the pharmacist and referral

% of customers with valid log record Site Influenced customer choice Changed customer choice Pharmacist asked Referred on

M01 93.33 40.00 80.00 13.33 M03* 100.00 0.00 20.00 20.00 M04 69.57 17.39 37.50 0 M05 55.56 0 28.57 0 M06 73.33 33.33 30.77 28.57 M08 0 0 0 0 R01 45.45 0 36.36 0 R02 66.67 20.00 100.00 25.00 R04 58.33 0 16.67 33.33 R05 52.38 6.25 47.62 26.32 R06 77.78 0 14.29 11.11 R07 43.75 0 12.50 25.00 R08 57.89 10.53 38.89 22.22

* incomplete customer log suspected

8.1.7.1 Appropriateness of products provided

The ratings of wound care product appropriateness were compared for the 2 raters. The Spearman’s correlation coefficient was 0.806 (p<0.001) for 239 products sold (where both codes 8 (not enough information) and 9 (not applicable) were set as missing) – the average intraclass correlation coefficient= 0.882 (95%CI 0.848-0.908, p<0.0001). One rater felt that there was sufficient information given to rate a further 34 products. When only items coded as “not applicable” were set as missing, the Spearman’s correlation coefficient was 0.730

71

(p<0.001) for 254 products sold (the average intraclass correlation coefficient= 0.732 (95%CI 0.657-0.791, p<0.0001)) giving 22 items set as not applicable by one rater but coded otherwise by the other rater. A review of these 22 items showed that one rater had not followed the instructions “to imagine the types of wounds customers are likely to use these products” for products purchased for a future use. For analysis, the 2 ratings were averaged, with 8 and 9 set as missing values. To overcome the 22 cases that were missing for one rater, the rating score of the other rater was substituted for the average value. The advanced dressings (foams, alginates, hydrocolloids and hydrogels etc) were more consistently given a higher appropriateness rating (Figure 8.25) with little difference between sites but ratings for passive dressings, first aid products, other dressing related products and tapes and bandages were more varied overall (Figure 8.25) and between the sites (Table 8.26).

38275612419563643N =Tapes & bandages

Simple first aid

Polymer dressings

Passive dressings

Other related prods

Hydrogels

Hydrocolloids

Foams

FilmsCadexomer iodine

Alginates

Ave

. app

ropr

iate

ness

ratin

g

4

3

2

1

0

-1

-2

Figure 8.25 Boxplot (showing median (black line), interquartile range (grey box) and

outliers) of average appropriateness rating/product for each dressing type

Table 8.26 Median of the average appropriateness rating/product for basic dressing products at each site

Average appropriateness rating/product Other dressing-related

products Passive dressings Simple first aid

products Tapes and bandages

Site Median Range N Median Range N Median Range N Median Range N

M01 0 1 1 - 1 3 0 2 2 - 2.5 4 M03 2 1 1.5 -0.5 - 1.5 7 0 1 1 M04 0.5 0.5 - 0.5 2 1.5 0 - 2.5 7 0 1.5 0.5 - 3 6 M05 0 1 -0.5 - 1 3 0.5 0 - 2.5 4 1.75 1 - 2.5 2 M06 1 0 - 1.5 7 -0.5 1 0 0 - 1 7 2.5 1.5 - 2.5 4 M08 0 1.5 1 1 1 - 1 1 1 1 R01 0.5 0 - 1 2 0.5 -0.5 - 1.5 2 1 1 - 2.5 6 2 1 R02 0.25 -0.5 - 1 2 0.5 0 - 1 2 0 0.5 0.5 - 0.5 2 R04 0 0.5 -0.5 - 1 10 0 0.5 1 R05 1 -1 - 1 6 0.5 -1 - 1 7 1 0.5 - 1 3 0.5 0.5 - 2.5 8 R06 0 1 1 - 1 1 0.5 0.5 - 1 3 0 R07 1 1 -0.5 -0.5 - 1 3 0.5 0.5 - 0.5 3 1 0 - 2.5 5 R08 1 0.5 - 1 3 1 -1 - 1.5 14 0 1 0 - 1 3

72

The overall mean of the average appropriateness rating/product for all products (excluding sports etc), was 1.52 (out of a best possible score of 3), although the median was 1, equivalent to “Limited potential to help healing” (Table 8.27). Again, there was variability between the sites, where lower scores were driven down by the higher proportion of basic dressings sold.

Table 8.27 Distribution of average appropriateness rating/product for all products sold for wound care in 2 weeks at each site

Site Mean Median Minimum Maximum Valid N M01 2.36 2.5 1 3 21 M03* 1.50 1.5 -0.5 3 11 M04 2.13 2.5 0 3 34 M05 1.05 1 -0.5 2.5 10 M06 1.59 1.5 -0.5 3 32 M08 1.17 1 1 1.5 3 M11 R01 1.66 1.25 -0.5 3 16 R02 1.45 1 -0.5 3 10 R04 1.13 1 -0.5 3 15 R05 0.94 1 -1 3 27 R06 1.75 1.5 0.5 3 8 R07 1.10 1 -0.5 3 15 R08 1.10 1 -1 3 26 Overall 1.52 1 -1 3 228

* probable incomplete customer log

8.1.7.2 Comparing wound types seen in 2 weeks with estimates

The estimates of the proportion of wound types seen in each pharmacy were compared with the percentage of wound types seen in the two week period of the customer log. When the values were averaged across all sites, there was a reasonably good match between estimates (pharmacist and pharmacy assistants) overall and the types of wounds seen in 2 weeks across the 13 sites completing the log (Figure 8.26). However, for individual sites, the level of agreement was much lower. Only three of the 12 possible correlations between estimates and the customer log approached significance (Table 8.28), with or without M03 whose customer log was potentially incomplete.

Average overall

0

10

20

30

40

50

60

70

80

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

None Burns Cuts and grazes Leg ulcers &pressure sores

Stitches &surgical wounds

Other wounds

% o

f wou

nd c

are

cust

omer

s

Figure 8.26 Average percentage of wound care customers with various wound types

across 13 sites – comparison of customer log, pharmacist (per profile) and the average pharmacy assistant (per assistant quiz) estimates

73

Table 8.28 Correlations between customer log, pharmacist (per profile) and the average pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types

Spearman’s rho correlation coefficient (p value, n) Wound type Customer log vs profile

estimate Log vs mean pharmacy

assistant estimate Profile vs mean pharmacy

assistant estimate None – for future use 0.589 (p=0.057 n=11) 0.435 (p=0.221 n=91) 0.660 (p=0.050 n=9) Burns -0.206 (p=0.520 n=12) 0.251 (p=0.515 n=9) 0.207 (p=0.592 n=9) Cuts and grazes 0.400 (p=0.198 n=12) -0.272 (p=0.478 n=9) -0.635 (p=0.066 n=9) Leg ulcers or pressure sores

0.317 (p=0.342 n=11) -0.389 (p=0.301 n=9) -0.072 (p=0.854 n=9)


-0.265 (p=0.431 n=11) -0.400 (p=0.286 n=9) 0.126 (p=0.748 n=9)

Other wounds 0.483 (p=0.188 n=9) 0.247 (p=0.555 n=8) -0.308 (p=0.553 n=6) Spearman’s rho (p value, n) excluding M03 for log comparisons None – for future use 0.765 (p=0.101 n=10) 0.432 (p=0.285 n=8) Burns -0.185 (p=0.586 n=11) -0.147 (p=0.728 n=8) Cuts and grazes 0.288 (p=0.390 n=11) 0.196(p=0.641 n=8) Leg ulcers or pressure sores

0.283 (p=0.428 n=10) -0.270 (p=0.518 n=8)


-0.144 (p=0.697 n=10) -0.429 (p=0.289 n=8)

Other wounds 0.396 (p=0.332 n=8) 0.398 (p=0.377 n=7) The pharmacist estimate of the proportion of wound care customers who sought dressings for future was the only estimate that correlated with the actual proportions recorded in the log. Two of the six possible correlations between estimates by pharmacists (per the wound care profile form) and pharmacy assistants (per the pharmacy assistant quiz) approached significance (dressings for future use and cuts and grazes). For cuts and grazes, however, the higher the pharmacist estimate of cuts and grazes, the lower the pharmacy assistant estimate. The comparison for each site can be seen in Figure 8.27 to Figure 8.31. The wound types over-estimated and under-estimated by pharmacists and assistants vary from each site. For example, in 7 of 13 sites, pharmacists (per the profile) underestimated the percentage of burns seen as indicated by the log, but 4 overestimated the proportion of burns seen and for two, the estimate was close to that recorded on the log.

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Figure 8.27 Comparison of customer log, pharmacist (per profile) and the average

pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – M01, M03 and M04

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pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – R01, R02 and R04

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Figure 8.30 Comparison of customer log, pharmacist (per profile) and the average pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – R05, R06 and R07

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pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – R08

8.2 DEVELOP INDEPENDENT QUALITY MEASURES

8.2.1 MYSTERY SHOPPER VISITS

The mystery shopper visits took the form of a product request. Few sites actually sought more information from the customer that might have been used to help the customer choose a more appropriate dressing than the passive dressing, Melolin. Four sites sought information about the size/location/appearance of wound (M06, R01, R05, R07) while one site gained information about the duration of wound (R05) (reported as ‘volunteered’ by the shopper). Six sites were recorded as providing information or advice about product selection or use: • That tape was needed to adhere Melolin (M08, R05) • That the shiny side of the Melolin should be placed onto the wound (M06, M01) • Economy issues i.e. buy a larger size and cut to size (M01); cost box versus singles (R02) • Discussion on whether needed waterproof dressing (scored as advice not information

seeking) (R07) No site offered more than 2 pieces of relevant advice, although there were 4 categories listed on the form. Three sites both sought information and gave advice, although neither were carried out at a high level since none explored the potential risks for poor wound healing and how to promote healing. At 2 sites (R06, M04), the mystery shoppers at the wound care section were ignored by the pharmacy assistants. At one of these sites, the assistant, who was stacking nearby shelves, was still able to ignore the customers despite have a box of Melolin dropped from the wound care shelf. The other site was busy at the time of the shopper visit, but the customer stood looking ‘puzzled’ at the wound care section for ‘some time’ before taking the product to the counter (despite the wound care section being adjacent to the counter).

8.2.1.1 Validation of mystery shopper data collection

Data recording sheets were completed independently by 2 visitors, both present for the same interaction at 7 sites. By and large, the independent responses of the 2 visitors about the same episode were in agreement. There was an average agreement between the raters of 93.6% for the questions relevant to each episode. Differences in the interpretation of the recording sheet

79

questions accounted for the differences in responses by the two visitors, as indicated by the shoppers at debrief: • R01 1 out of 14 possible questions mismatched. In response to the question, was assistance

given to find a requested product, one visitor wrote “sort of” and recorded this response as ‘yes’ while the other wrote “guided us around the corner to individual packages rather than packs” and recorded this as ‘no’.

• R02 Nil mismatches. The only difference was the description of advice recorded (although both visitors indicated that no product selection or use or wound care advice was given). One visitor noted a discussion on the relative costs of a single dressing versus a box while the other reported no response the discussions between the shoppers. This discussion provided an opportunity to the assistant to be more involved. Visit at around midday.

• R04 Nil mismatches. Both shoppers commented on relative expense of the product Visit at around midday

• R05 3 out of a 16 possible questions. This was the first mystery shopping episode conducted. There were differences in whether the visitors were approached before reaching the wound care section – one visitor noted that it was “about the same time” and circled ‘yes’, the other circled ‘no’, and differences in the recording of time taken before assistance was provided, due to differences in the interpretation of the question (one visitor interpreted this as the time to assistance after the wound care section were reached and the other took the time from the entrance into the shop). One visitor reported receiving assistance and the other said no assistance to find the requested product (since this visitor noted the assistant and the visitors reached the wound care section at the same time). One visitor noted that the assistant sought 2 categories of information (duration of wound and size/location/appearance of wound) while the other tick only size/location/appearance of wound and indicated that she has volunteered information on the duration of the wound. Visit at 10.30am

• R06 Nil mismatches. Visit at 11.30am. The visitors both commented that they were ignored by the assistant who was unpacking stock right next to them.

• R07 3 out of a 16 possible questions. There were differences in the recording of time taken before assistance was provided, due to differences in the interpretation of the question. One visitor reported that the assistant asked for more information (the size/location/appearance of wound) while the other said no information had been sought although there was discussion related to whether a waterproof dressing might be needed. Both visitors said that advice was given but one classified the advice (about waterproof dressings) as advice about a ‘better product’. The other visitor classified the advice as ‘other’ on the grounds that she did not consider a waterproof dressing to be a better product for the scenario.

• R08 Nil mismatch.

8.2.1.2 Mystery shopper scores

The mystery shoppers’ global rank of the shopping episode was compared to the mystery shopping score. As expected, the ranking and ratings were highly correlated (Spearman’s correlation coefficient = 0.876, p<0.0001) but since the correlation coefficient was less than 1, these two variables were felt to address overlapping but different domains of service quality.

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Mystery shopper score

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Figure 8.32 Comparison of mystery shopper score and mystery shopper rank for each

study site (dashed line = linear regression line of best fit)

The mystery shopper scores and rankings were compared to the audit quality assessments. There was little correlation between the mystery shopper ratings and the audit ratings (Table 8.29), with only service level and display for self-selection being related to mystery shopper rank. This lack of correlation may be due to the relatively poor performance of M03 and M04 at the mystery shopper visits (Figure 8.33).

Table 8.29 Spearman’s correlations between quality assessments at audit and mystery shopper rank and score (n=14)

Audit rating Mystery shopper ranking Mystery shopper score

Overall quality 0.326, p=0.255 0.219, p=0.452 Service level 0.480, p=0.082 0.393, p=0.165 Space & facilities needs met 0.345, p=0.227 0.262, p=0.365 Display aids self-selection 0.522, p=0.056 0.402, p=0.154

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Figure 8.33 Scatterplot of overall service quality rated at audit and mystery shopper rank and score (showing line of identity – maximum shopper score set at 9 based on information actually sought and given)

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At site M03, while the assistant was not busy, the pharmacist was and at site M04, the shop was busy.

8.2.2 INDEPENDENT QUALITY SCORES

The independent quality score linked the mystery shopper rank and score and the audit overall quality score. Figure 8.34 shows the scatterplots between the independent quality score and: • Mystery shopper rank • Mystery shopper score • Audit overall quality rating


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Figure 8.34 Scatterplots of independent quality score versus mystery shopper rank and

score and overall service quality rated at audit This independent score also increased as the following ratings increased: • Audit service level rating (rudimentary to advanced) (rho=0.905 p<0.0001) • Audit space and facilities needs met rating (rho=0.618 p=0.019) • Audit display aids self-selection rating (rho=0.811 p<0.001) The combined quality score linked the factors in the independent quality score with the appropriateness of products sold in a 2 week interval, as rated by 2 experts. The appropriateness score was correlated only with the combined quality score (rho=0.705 n=13 p=0.007) but not with mystery shopper rank or score or any of the 4 audit rating or the independent quality score. The combined score correlated with two of the other audit quality measures (service level and display for self-selection but not the extent to which space and facility needs were met (Table 8.30).

Table 8.30 Correlations between the combined quality score and independent audit quality measures

Spearman’s rho and p value (n=13)

Service level Space & facility needs Display for self-selection 0.837, p<0.001 0.396, p=0.181 0.664, p=0.013

A summary of scores across the range of independent quality measures is shown in Table 8.31. These measures, and the remaining 3 audit quality assessments, were compared against potential indicators.

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Table 8.31 Summary of overall quality measures per site

Site

Mystery shopper rank

(max 14)


(max 9)


(max 100)

Independent quality score

(max 200)

Mean appropriate-ness rating of

products sold (max 3)

Combined quality score

(max 100) M01 14 5 95 158.33 2.36 78.97 M03 4 2 91 111.00 1.50* 53.67* M04 6 1 83 106.33 2.13 59.14 M05 7 2 43 73.00 1.07 36.24 M06 13 6 50 113.33 2.08 60.93 M08 9 4 30 73.33 1.17 37.41 M11 2 2 17 30.33 - 21.22† R01 12 5 43 99.67 1.75 52.67 R02 8 3 64 100.67 1.45 49.67 R04 5 1 22 42.00 1.13 26.59 R05 11 6 69 125.67 0.94 52.38 R06 1 1 44 50.67 1.75 36.33 R07 10 4 51 97.67 1.12 44.95 R08 3 1 50 63.33 1.07 33.02

* likely incomplete data collection † since no log was provided, the median average appropriateness score (1) was imputed and a combined score calculated

8.2.3 CUSTOMER TELEPHONE SURVEY VERSUS QUALITY RATING

Generally, pharmacies with higher combined quality scores recruited more customers for the telephone survey (Table 8.32). While only a small number of customers were surveyed, some limited corroboration of the quality scores was found. By and large, customers gave pharmacies favourable ratings but of the 5 customers giving a less than very satisfactory rating, three went to pharmacies each with a combined quality score of less than 50% (Table 8.32). The customer who attended M03 was not a regular customer of that pharmacy while the customer from R01 had a chronic leg ulcer managed by the district nurse.

Table 8.32 Customer recruitment, response and service quality ratings versus combined quality score

Site Combined quality score (max 100)

No. customers recruited

Surveys responses

Level of help received from staff

Overall, how wound care needs met

M01 78.97 1 M06 60.93 M04 59.14 2 1 Excellent Excellent M03 53.67 1 1 Very good Very good R01 52.67 3 2 Excellent; Excellent Very good; Excellent R05 52.38 R02 49.67 6 3 Excellent; Excellent;

Very good Excellent; Excellent;

Excellent R07 44.95 M08 37.41 1 1 Excellent Very good R06 36.33 M05 36.24 R08 33.02 1 1 Good Good R04 26.59 M11 21.22

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8.3 COMPARISON OF INDICATORS WITH INDEPENDENT QUALITY MEASURES

8.3.1 PHARMACY CHARACTERISTICS

The location of a pharmacy (rural versus metropolitan) did not significantly influence independent quality measures (Figure 8.35 and 8.1.1.2). After excluding the 3 more advanced wound care pharmacies , that were all located in the metropolitan area, the median combined quality score for metropolitan pharmacies was lower than that of rural sites, although not significant. Similarly, pharmacy size did not influence the quality ratings (Figure 8.36 and 8.1.1.2). Banner group membership (3 sites) did not significantly influence mystery shopper rank (p=0.225),any audit quality measure (overall quality p=0.885, service level p=0.456, space and facility needs p=0.225, display for self-selection p=0.669), the average appropriateness of products sold rating (p=0.811), the independent quality score (p=0.368) or the combined quality score (p=0.456). The mystery shopper scores for banner group sites, however, was significantly lower (all had a score=1) than non-banner group sites (p=0.011).

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Figure 8.35 Boxplots of A. Mystery shopper rank, B Mystery shopper score, C.

Appropriateness of products sold rating, D. Independent quality score, E. Combined quality score and F. Combined quality score (*excluding 3 more advanced metropolitan pharmacies) versus pharmacy location

Quality Care Pharmacy Program accreditation was not significantly related to mystery shopper rank (p=0.310) or score (p=1.000), the audit overall quality rating (p=0.271), service level rating (p=0.271), the average appropriateness of products sold (p=0.236) or the independent and combine quality scores (p=0.310 and p=0.612 respectively). Only the audit rating on the extent to which space and facility needs were met (median score accredited=55, non-accredited=26, p=0.063) and the arrangement of the wound care display to aid self-selection (median score accredited=41, non-accredited=13, p=0.042) were significantly higher in accredited pharmacies.

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Figure 8.36 Boxplots of A. Mystery shopper rank, B Mystery shopper score, C.

Appropriateness of products sold rating, D. Independent quality score, E. Combined quality score and F. Combined quality score (excluding 3 more advanced pharmacies) versus pharmacy size

8.3.2 LAYOUT OF WOUND CARE SECTION

The signage of the wound care area of the pharmacy was significantly related to perceived quality assessments at audit (see Figure 8.9) but not to mystery shopper rank (p=0.518) or score (p=0.530), the independent quality score (p=0.228), the average appropriateness of products sold rating or the combined quality score (Figure 8.37), although the trend was for higher quality scores in sites where the signs read “wound care” compared to no sign or a sign that read “first aid”.

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Figure 8.37 Boxplots of A. Appropriateness of products sold rating and B. Combined

quality score versus wound care signage

The further the pharmacist had to walk from the dispensary to the wound care section, the higher the average appropriateness rating of products sold (Spearman’s rho=0.593 n=13

85

p=0.033) but this may be related to the amount of shelf space occupied by wound care products which also increased as the average appropriateness rating of products sold (Spearman’s rho=0.550 n=13 p=0.052) (Figure 8.38).

Steps from dispensary to wound care

1614121086420

Ave

app

ropr

iate

ness

ratin

g

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.8

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Shelf space for wound care (m)

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R08R07

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M01BA

Figure 8.38 Appropriateness of products sold rating versus A. Distance from the

dispensary to the wound care section and B. Number of linear metres of shelving for wound care products

The amount of shelving for first aid products and the total amount of dressings shelving did not correlate with quality measures. However, the percentage of total dressings shelves for wound care shelves was related to the independent quality score (rho=0.466 n=13 p=0.093), possibly due to the influence of the audit quality measures reported in 8.1.1.2. The extent to which the wound care section could be viewed from the dispensary had a affected the mystery shopper ranking approached significance (Kruskall Wallis test p=0.072) but a trend with increasing visibility was not apparent (the sites with the most visible wound care sections had the highest median mystery shopper rank and the second most visible sites having the lowest median rank). The visibility of the wound care section was also related to the audit rating of the extent to which space and facilities needs were met (p=0.049) (Figure 8.39).

653N =


Mys

tery

sho

pper

rank

ing

16

14

12

10

8

6

4

2

0

M08

653N =


Audi

t Spa

ce &

faci

lity

need

met

100

80

60

40

20

0

M03





Can see most/all of sectionPartly hidden, customers not seen

Figure 8.39 Boxplot of visibility of the wound care section from the dispensary versus

mystery shopper ranking and audit rating of space and facility needs met

86

The extent to which manufacturers’ shelving aids were used was not significantly related to any quality measure, but the arrangement of products in terms of neatness and layout was related to some quality measures. The extent to which the wound care products were together and not dispersed among first aid products and tapes was related to the audit overall quality level, and the independent quality score and combined quality score (which incorporate the audit score) (Figure 8.40). There were trends towards increased quality with better product arrangement for mystery shopper measures and the appropriateness of products sold but these were not significant. The other 3 audit assessments, service level (p=0.025), space and facilities (p=0.036) and display to aid self-selection (p=0.059) were also related to product arrangement. Similar trends were observed for the extent to which different products could be distinguished just by looking at the shelves (Figure 8.41). The audit overall quality rating, independent quality score and the combined quality score increased as the layout improved (as did the other 3 audit assessments, service level (p=0.011), space and facilities (p=0.038) and display to aid self-selection (p=0.026). The mystery shopper rank and score was not related to layout of products but there was a trend towards more appropriated products being sold where the product layout was better (p=0.115).

293N =

Wound care products together?

Yes, well arrangedMostly

Not really

Mys

tery

sho

pper

rank

ing

16

14

12

10

8

6

4

20

293N =



Not really

Mys

tery

sho

pper

sco

re

7

6

5

4

3

2

10

293N =



Not really

Audi

t ove

rall

qual

ity le

vel

120

100

80

60

40

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0

292N =



Not really

Ave.

app

ropr

iate

ness

2.6

2.42.2

2.01.8

1.61.4

1.21.0

.8293N =



Not really

Inde

pend

ent q

ualit

y sc

ore

180

160

140

120

100

80

60

4020

293N =



Not really

Com

bine

d qu

ality

sco

re

90

80

70

60

50

40

30

2010

P=0.736 CBA P=0.028P=0.257

D EP=0.328 P=0.053 P=0.084F

Figure 8.40 Boxplots of A. Mystery shopper rank, B Mystery shopper score, C. Audit

rating of overall service quality, D. Appropriateness of products sold rating, E. Independent quality score and F. Combined quality score versus arrangement of wound care stock

87

77N =

Distinguish products by looking?

Mostly, some unseenNot really

Mys

tery

sho

pper

rank

ing

16

14

12

10

8

6

4

20

77N =



Mys

tery

sho

pper

sco

re

7

6

5

4

3

2

1

077N =



Audi

t ove

rall

qual

ity

120

100

80

60

40

20

0

76N =



Ave

appr

opria

tene

ss

2.6

2.4

2.2

2.0

1.8

1.6

1.4

1.2

1.0.8

M06

77N =



Inde

pend

ent q

ualit

y sc

ore

180

160

140

120

100

80

60

4020

R06

M01

77N =



Com

bine

d qu

ality

sco

re

90

80

70

60

50

40

30

2010

R06

M01

M06

P=0.696 CBA P=0.021P=0.655

P=0.035D E FP=0.115 P=0.048

Figure 8.41 Boxplots of A. Mystery shopper rank, B Mystery shopper score, C. Audit

rating of overall service quality, D. Appropriateness of products sold rating, E. Independent quality score and F. Combined quality score versus ease of distinguishing products by observation

8.3.3 PHARMACY CHARACTERISTICS AND WORKLOAD

The total number of opening hours was related to the audit overall quality score and the two scores that included the audit score in their calculation (independent quality score and combined quality score) (Figure 8.42 and Table 8.33). These relationships were still significant after the benchmark site with the longest opening hours was excluded.

Opening hours/week

120110

10090

8070

6050

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Com

bine

d qu

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M01C

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Opening hours/week

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ore

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M01B

Opening hours/week

120110

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Inde

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ore

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Opening hours/week

120110

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Aud

it ov

eral

l qua

lity

leve

l

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Opening hours/week

120110

10090

8070

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Aud

it ov

eral

l qua

lity

leve

l

100

80

60

40

20

0

R08R06

R05

R04

R02

R01

M11

M08

M06

M05

M04

M03M01A

Figure 8.42 Opening hours per week versus A. Audit rating of overall service quality, B.

Independent quality score and C. Combined quality score

The audit quality measures (overall, service level and display) and the independent and combined quality scores all increased as the number of prescriptions filled per week increased (Figure 8.43and Table 8.33 – service level is not shown as it closely matches the audit overall quality rating). However, the number of effective full-time pharmacists, who would fill

88

prescriptions, was not related to any quality measure. The number of EFT pharmacy assistants was only significantly related to the audit overall quality rating (the quality rating increased as the number of EFT pharmacy assistants increased (Table 8.33)). The number of EFT pharmacy assistants was not related to the service quality as indicated by the mystery shopper visit or the appropriateness of products sold.

No. prescriptions/week

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

2001

-300

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Aud

it ov

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l qua

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leve

l

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R08R06

R05

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M04M03M01


Com

bine

d qu

ality

sco

re

90

80

70

60

50

40

30

20

R08R06

R05

R04

R02 R01

M11

M08

M06

M05

M04

M03

M01

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0


Com

bine

d qu

ality

sco

re

90

80

70

60

50

40

30

20

R08R06

R05

R04

R02 R01

M11

M08

M06

M05

M04

M03

M01

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

No. prescriptions/weekA

udit

disp

lay

self-

sele

ctio

n

80

70

60

50

40

30

20

100

R08

R06

R05

R04

R02

R01

M11

M08

M06

M05

M04

M03

M01

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

No. prescriptions/weekA

udit

disp

lay

self-

sele

ctio

n

80

70

60

50

40

30

20

100

R08

R06

R05

R04

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M11

M08

M06

M05

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M03

M01

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

2001

-300

0

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0

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≤30

0


Inde

pend

ent q

ualit

y sc

ore

180

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60

4020

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M01

2001

-300

0

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≤30

0


Inde

pend

ent q

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y sc

ore

180

160

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120

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60

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R08R06

R05

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R02 R01

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M01

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

2001

-300

0

1201

-200

0

801-

1200

301-

800

≤30

0

A

C

B

D

Figure 8.43 Number of prescriptions dispensed per week versus A. Audit rating of

overall service quality, B. Audit rating of display to aid self-selection, C. Independent quality score and D. Combined quality score

While the number of EFT pharmacist did not relate to quality measures, the number of pharmacists (irrespective of whether full-time or part-time) was related to audit quality measures and the independent and combined quality scores (Table 8.33). The relationships between the number of recent graduates and the number of more experienced pharmacists and the various quality measures (Table 8.33) possibly reflect the influence of pharmacist staffing on quality. The staffing levels, as indicated by the number of hours/week when more than one pharmacist was on duty, was related, negatively, to the appropriateness. As the number of hours where more than one pharmacist was on duty increased, the appropriateness of products sold decreased (Table 8.33 and Figure 8.44). The estimated total number of pharmacist hours (opening hours plus the number of hours when more than 1 pharmacist is on duty) was not related to any quality measure (Table 8.33), but as the number of hours each pharmacist worked (calculated as estimated total pharmacist hours divided by the total number of pharmacists i.e. pharmacist hours/actual pharmacist) increased, two audit measures, the combined quality score and the appropriateness of products sold declined ((Table 8.33 and Figure 8.44). Total pharmacist hours per EFT pharmacist was not related to any quality measure.

89

Table 8.33 Spearman’s correlations between quality measures and indicators of workload and staffing levels

Mystery shop Audit Workload & staffing

indicators

Stat-istic Rank Score Overall

qualityService

level Space

& facility

Display – self-select

Ave. approp-riate-ness

Indep-endent quality score

Comb-ined

quality score

rho 0.309 0.309 0.652 0.657 0.329 0.462 0.307 0.691 0.621 p value 0.304 0.304 0.016 0.015 0.273 0.112 0.331 0.009 0.023

Opening hours/ week

N 13 13 13 13 13 13 12 13 13 rho 0.368 0.302 0.515 0.607 0.405 0.663 0.262 0.579 0.562 p value 0.216 0.316 0.072 0.028 0.170 0.013 0.411 0.038 0.046

Number of prescriptions / week N 13 13 13 13 13 13 12 13 13

rho 0.135 -0.095 0.340 0.271 0.386 0.336 -0.171 0.257 0.081 p value 0.661 0.758 0.255 0.370 0.193 0.262 0.596 0.396 0.793

Effective full-time equivalent pharmacists N 13 13 13 13 13 13 12 13 13

rho -0.133 -0.319 0.579 0.423 0.310 0.388 -0.037 0.255 0.169 p value 0.665 0.289 0.038 0.150 0.302 0.191 0.909 0.401 0.581

Effective full-time equivalent pharmacy assistants

N 13 13 13 13 13 13 12 13 13

rho 0.017 -0.299 0.741 0.627 0.429 0.457 0.476 0.408 0.478 p value 0.959 0.346 0.006 0.029 0.165 0.135 0.139 0.188 0.116

No. pharmacists registered <5 years N 12 12 12 12 12 12 11 12 12

rho 0.296 0.069 0.513 0.687 0.562 0.517 0.414 0.547 0.588 p value 0.350 0.832 0.088 0.014 0.057 0.085 0.206 0.066 0.044

No. pharmacists registered 5 years or more N 12 12 12 12 12 12 11 12 12

rho 0.234 -0.071 0.579 0.672 0.561 0.489 0.359 0.499 0.515 p value 0.464 0.825 0.048 0.017 0.057 0.107 0.279 0.099 0.087

Total number pharmacists

N 12 12 12 12 12 12 11 12 12 rho -0.158 -0.033 -0.199 -0.229 -0.100 0.015 -0.715 -0.133 -0.377p value 0.606 0.916 0.515 0.452 0.746 0.960 0.009 0.665 0.204

Hours/week when more than one pharmacist N 13 13 13 13 13 13 12 13 13

rho 0.093 0.081 0.457 0.446 0.352 0.452 -0.053 0.412 0.264 p value 0.762 0.791 0.116 0.127 0.239 0.121 0.871 0.162 0.384

Estimated total No. p’cist hrs (opening hrs + 1x hrs >1 p’cist)

N 13 13 13 13 13 13 12 13 13

rho -0.214 0.135 -0.552 -0.647 -0.490 -0.420 -0.625 -0.417 -0.585p value 0.505 0.675 0.063 0.023 0.106 0.174 0.040 0.178 0.046

Estimated total p'cist hrs/total no. p'cists N 12 12 12 12 12 12 11 12 12

rho 0.022 0.282 0.105 0.197 -0.160 0.083 0.199 0.245 0.333 p value 0.943 0.351 0.733 0.518 0.602 0.788 0.536 0.419 0.266

Estimated total p’cist hrs/No. EFT p’cists N 13 13 13 13 13 13 12 13 13

Providing wound care products to aged care facilities was not significantly related to mystery shopper rank (p=0.465) or score (p=0.711), the audit overall quality rating (p=0.647), service level rating (p=0.584), the extent to which space and facility needs were met (p=0.584), the average appropriateness of products sold (p=0.336) or the independent and combine quality scores (p=0.584 and p=0.361 respectively). Only the audit rating of the arrangement of the wound care display to aid self-selection (median score yes=41, no=15, p=0.054) were tended to be higher in pharmacies providing wound care products to aged care facilities. Providing wound care products to community nurses is likely to be significantly related to quality since 2 of the more advanced sites (M01 and M04) provided these services while the other, M03, was missing this information (although stock holdings suggest that this service is provided). These

90

relationships were not tested statistically because of the small number of sites providing the service.

No. Hrs/wk > 1 pharmacist on duty

6050403020100-10

Ave

. app

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ness

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Total p'cist hrs/total no. p'cists

706050403020100

Ave

. app

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R08

R06

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M05

M04

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M01A B

Figure 8.44 Influence of pharmacist staffing levels on the average appropriateness of

products sold rating; A. Number of hours/week with more than one pharmacist on duty and B. total number of pharmacist hours/total number of pharmacists

8.3.3.1 Proprietor/Manager perceptions of service and quality

The level of agreement between the proprietors’ perceptions of quality and the independent quality measures was slight (Table 8.34). As the proprietors’ rating of overall service quality increased, so to did the average appropriateness rating of products sold (Figure 8.45) and the combined independent quality score. Conversely, as the proprietors’ rating of the extent to which space and facility needs were met decreased, the average appropriateness rating of products sold increased (Figure 8.45).

Table 8.34 Spearman’s correlations between quality measures and proprietors’ perceptions of quality

Mystery shop Audit Proprietor’s perceptions


qualityService

level Space

& facility




Comb-ined

quality score

rho 0.220 -0.155 0.432 0.380 0.138 0.324 0.576 0.336 0.487 p value 0.470 0.614 0.141 0.200 0.654 0.280 0.050 0.262 0.091

Overall quality

N 13 13 13 13 13 13 12 13 13 rho 0.242 0.020 0.178 0.234 -0.132 0.349 0.485 0.253 0.388 p value 0.426 0.949 0.561 0.441 0.667 0.243 0.110 0.404 0.190

Service level

N 13 13 13 13 13 13 12 13 13 rho -0.366 -0.327 -0.054 -0.188 0.229 -0.174 -0.619 -0.242 -0.366p value 0.218 0.276 0.861 0.539 0.452 0.570 0.032 0.425 0.218

Space & facility

N 13 13 13 13 13 13 12 13 13 rho -0.366 -0.386 -0.025 -0.061 -0.028 -0.206 0.084 -0.231 -0.187p value 0.218 0.193 0.936 0.844 0.929 0.500 0.794 0.447 0.540

Display to aid self-selection

N 13 13 13 13 13 13 12 13 13

91

Proprietor overall quality rating

120100806040200

Ave

. app

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M01

Proprietor Space/facility needs

120100806040200

Ave

. app

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2.0

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R08

R06

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M08

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M01A B

Figure 8.45 The average appropriateness of products sold rating versus A. Proprietors’

overall service quality rating and B. Proprietors’ rating of extent to which wound care space and facility needs are met

The availability of written wound care information that customers could take away was not significantly related to any quality measure, nor were proprietor’s reports of assistants seeking pharmacist input into wound care transactions, taking a detailed history of a wound or persuading customers to select a more appropriate product. Pharmacies where there was an opportunity to monitor wound healing progress because wound care customers were seen more than once did not have significantly different quality ratings than those without this opportunity. Of the pharmacies who had the opportunity to monitor wounds, there was no difference in any quality measure for those that routinely monitored progress in a given episode of wound care and those that did not. Pharmacy reports of the number of wound care customers referred to other health professionals or services/clinics by the pharmacy was related to the combined quality score (Spearman’s rho=0.497, n= 13 p=0.084) (Figure 8.46), but this relationship was weaker after the exclusion of the benchmark site, M01 (rho=0.423, n=12 p=0.171). Other quality measures were not related to customer referral by the pharmacy to others. Pharmacies who had customers referred to them by other health professionals for wound care services, however, had a significantly higher average appropriateness ratings for the products sold in the 2 weeks of the customer log (p=0.028) (Figure 8.47).

No. customers referred on/4wks

3020100-10

Com

bine

d qu

ality

sco

re

90

80

70

60

50

40

30

20

R08 R06

R05

R04

R02R01

M11

M08

M06

M05

M04M03

M01 p=0.084

Figure 8.46 Combined quality score versus number of wound care customers referred

to others in the last 4 weeks

92

56N =

Has customers referred to p'cy

yesnoA

ve a

ppro

pria

tene

ss

2.6

2.4

2.2

2.0

1.8

1.6

1.4

1.2

1.0.8

R04

Figure 8.47 Boxplot of average appropriateness rating of products sold versus receipt

of wound care referrals from other health professionals

8.3.3.2 Stock and sales

As the proportion of turnover made up by wound care increased, 3 of the 4 audit quality ratings, the independent and combined quality scores and the average appropriateness of products sold tended to increase (Table 8.35 and Figure 8.48), however, after excluding the benchmark site (M01), the appropriateness rating and independent quality score relationships with percentage turnover from wound care were no longer important. Turnover was not related to the mystery shopper visit or the extent to which space and facility needs were met.

Table 8.35 Spearman’s correlations between quality measures and the percentage of turnover from wound care

Mystery shop Audit Stat-istic Rank Score Overall

qualityService

level Space

& facility




Comb-ined

quality score

rho 0.347 0.010 0.774 0.772 0.462 0.706 0.657 0.578 0.732 p value 0.296 0.977 0.005 0.005 0.152 0.015 0.039 0.063 0.010

Percentage of turnover from wound care

N 11 11 11 11 11 11 10 11 11 None of the quality ratings were significantly different between sites reporting a recent “out of stock” for wound care products and those that did not, nor was supplying a second choice product because of “out of stocks” related to any quality measure.

93

% turnover from wound care>54-

5

3-4

2-3

1-2

<1

Audi

t ove

rall

serv

ice

qual

ity120

100

80

60

40

20

0

R08R06

R05

R01

M11

M08

M06

M05

M04M03 M01

% turnover from wound care

Audi

t dis

play

for s

elf-s

elec

tion 80

70

60

50

40

30

20

100

R08

R06

R05

R01

M11

M08M06

M05

M04 M03

M01


Ave.

app

ropr

iate

ness

2.6

2.4

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1.8

1.6

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1.2

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R08

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R01

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M06

M05

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M03

M01


Inde

pend

ent q

ualit

y sc

ore

180

160

140

120

100

80

60

4020

R08

R06

R05

R01

M11

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Figure 8.48 Percentage of turnover from wound care versus A. Audit overall quality

rating and B. display for self-selection rating, C. Average appropriateness rating of products sold, D. Independent and D. Combined quality scores

The range and level of stock carried as recorded at audit (since there was no missing data for this measure) was compared against the quality measures. Two aspects of stock holding were considered, the range of stock carried (a combination of number of brands carried and number of different dressing sizes) and a stock level score (stock range and the quantity of stock carried). Not unexpectedly, the stock range scores for a number of dressing classes and the total stock range score were positively correlated with the audit overall quality rating and the service level rating (since stock range was an aspect considered as part of these quality assessments) (Table 8.36). The range of polymer, alginate and hydrofibre dressings, and zinc paste bandages influenced the audit quality rating while greater stock ranges of foam, polymer and hydrofibre dressings and zinc paste bandages were a marker for the sale of more appropriate dressings. The combined quality score increased as the stock range score for polymers and alginates and the total stock range score increased (Figure 8.49). The stock range scores of films, hydrocolloids, hydrogels and cadexomer iodine were not related to any quality measure. The stock range scores for passive dressings and first aid products did not differ between sites and so were not related to any quality measure. The aspects of quality assessed by the mystery shopper visit were not related to stock range. Excluding M01 from the analysis meant that only the following relationships remained of interest: • Average appropriateness rating of products sold versus the stock range scores for polymer

dressings(rho=0.762 n=12 p=0.004), zinc paste bandages (rho=0.530 n=12 p=0.077) and the total stock range score (rho=0.582 n=12 p=0.047)

• The same 3 audit ratings were related to the stock score for alginate dressings (n=13, overall quality rho=0.644 p=0.018, service level rho=0.566 p=0.044, display for self-selection rho=0.577 p=0.039)

94

Table 8.36 Audit stock range scores for dressing categories and sum of stock range scores overall

Mystery shop Audit Stock range (No. brands x No.

sizes)


qualityService

level Space

& facility




Comb-ined

quality score

rho 0.294 0.239 0.356 0.356 0.306 0.080 0.105 0.405 0.454 p value 0.307 0.411 0.211 0.211 0.287 0.786 0.733 0.151 0.103

Films

N 14 14 14 14 14 14 13 14 14 rho -0.115 -0.308 0.416 0.402 0.442 0.270 0.512 0.226 0.359 p value 0.695 0.283 0.139 0.154 0.114 0.351 0.074 0.438 0.207

Foams

N 14 14 14 14 14 14 13 14 14 rho -0.246 -0.142 0.254 0.113 -0.057 0.076 0.328 -0.025 0.047 p value 0.396 0.629 0.381 0.699 0.848 0.795 0.274 0.933 0.874

Hydrocolloids

N 14 14 14 14 14 14 13 14 14 rho -0.145 -0.161 0.357 0.323 0.180 0.181 0.280 0.202 0.216 p value 0.620 0.582 0.210 0.260 0.537 0.536 0.355 0.490 0.459

Hydrogels

N 14 14 14 14 14 14 13 14 14 rho 0.025 -0.066 0.477 0.532 0.210 0.399 0.801 0.393 0.569 p value 0.931 0.823 0.084 0.050 0.470 0.158 0.001 0.164 0.034

Polymers

N 14 14 14 14 14 14 13 14 14 rho 0.109 -0.028 0.695 0.626 0.294 0.637 0.357 0.511 0.506 p value 0.711 0.924 0.006 0.017 0.308 0.014 0.231 0.062 0.065

Alginate

N 14 14 14 14 14 14 13 14 14 rho -0.105 -0.153 0.489 0.520 0.280 0.343 0.587 0.322 0.405 p value 0.720 0.603 0.076 0.057 0.332 0.230 0.035 0.262 0.151

Hydrofibre

N 14 14 14 14 14 14 13 14 14 rho 0.039 -0.160 0.432 0.354 0.235 0.177 0.469 0.157 0.314 p value 0.894 0.585 0.123 0.215 0.418 0.545 0.106 0.592 0.275

Cadexomer iodine

N 14 14 14 14 14 14 13 14 14 rho -0.155 -0.235 0.481 0.399 0.237 0.307 0.523 0.229 0.378 p value 0.596 0.419 0.081 0.158 0.416 0.287 0.067 0.430 0.183

Zinc paste bandages

N 14 14 14 14 14 14 13 14 14 rho -0.062 -0.209 0.556 0.501 0.261 0.380 0.659 0.305 0.473 p value 0.834 0.472 0.039 0.068 0.368 0.180 0.014 0.289 0.088

Sum of stock range scores

N 14 14 14 14 14 14 13 14 14

Stock range score - polymers

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Figure 8.49 Combined quality score versus stock range scores for A. polymer

dressings and B. alginate dressings, and total stock range score

When the quantity of stock was also taken into account, the relationships of interest differed only slightly. The audit overall quality level increased as stock level scores for foams,

95

hydrocolloids, polymers, alginates and hydrofibre dressings and zinc paste bandages (Table 8.37) as well as the total stock level score increased. The relationships of interest between the stock level scores of the dressing categories and the average appropriateness rating of products sold were the same, however, the total stock level score was not related to the appropriateness of products sold. In addition to alginates, polymer dressing stock level scores were related to the independent quality score. Stock levels of alginates were no longer related to the combined quality score, however, zinc paste bandage stock levels were related to the combined quality score.

Table 8.37 Audit stock level scores for dressing categories and sum of stock level scores overall

Mystery shop Audit Stock level score (No. brands x No. sizes x No. units)


qualityService

level Space

& facility




Comb-ined

quality score

rho 0.294 0.239 0.356 0.356 0.306 0.080 0.105 0.405 0.454 p value 0.307 0.411 0.211 0.211 0.287 0.786 0.733 0.151 0.103

Films

N 14 14 14 14 14 14 13 14 14 rho -0.159 -0.372 0.520 0.462 0.451 0.321 0.506 0.263 0.379 p value 0.586 0.190 0.057 0.096 0.105 0.264 0.077 0.364 0.181

Foams

N 14 14 14 14 14 14 13 14 14 rho -0.091 -0.093 0.560 0.422 0.152 0.402 0.318 0.287 0.299 p value 0.758 0.751 0.037 0.133 0.605 0.155 0.289 0.319 0.299

Hydrocolloids

N 14 14 14 14 14 14 13 14 14 rho -0.114 -0.201 0.439 0.411 0.376 0.228 0.354 0.226 0.269 p value 0.697 0.491 0.116 0.145 0.185 0.433 0.236 0.437 0.353

Hydrogels

N 14 14 14 14 14 14 13 14 14 rho 0.157 0.130 0.593 0.686 0.421 0.612 0.577 0.504 0.580 p value 0.592 0.657 0.026 0.007 0.134 0.020 0.039 0.066 0.030

Polymers

N 14 14 14 14 14 14 13 14 14 rho 0.092 0.022 0.781 0.675 0.404 0.634 0.159 0.527 0.444 p value 0.756 0.942 0.001 0.008 0.152 0.015 0.605 0.053 0.112

Alginate

N 14 14 14 14 14 14 13 14 14 rho -0.072 -0.146 0.486 0.517 0.265 0.340 0.616 0.325 0.414 p value 0.808 0.618 0.078 0.058 0.360 0.234 0.025 0.256 0.141

Hydrofibre

N 14 14 14 14 14 14 13 14 14 rho 0.113 -0.098 0.450 0.381 0.256 0.232 0.405 0.188 0.325 p value 0.700 0.738 0.106 0.178 0.376 0.424 0.170 0.521 0.256

Cadexomer iodine

N 14 14 14 14 14 14 13 14 14 rho -0.026 -0.136 0.579 0.506 0.359 0.403 0.607 0.347 0.478 p value 0.930 0.643 0.030 0.065 0.208 0.153 0.028 0.224 0.084

Zinc paste bandages

N 14 14 14 14 14 14 13 14 14 rho -0.034 -0.035 -0.172 -0.172 -0.241 -0.448 0.000 -0.103 -0.034p value 0.907 0.905 0.556 0.556 0.407 0.108 1.000 0.726 0.907

Passive dressings

N 14 14 14 14 14 14 13 14 14 rho -0.020 -0.064 0.721 0.615 0.306 0.368 0.464 0.434 0.515 p value 0.946 0.828 0.004 0.019 0.287 0.196 0.110 0.121 0.059

Sum of stock level scores

N 14 14 14 14 14 14 13 14 14 Although not statistically significant, the correlation coefficients for all the quality measures and the stock level score for passive dressings were negative or zero.

96

After excluding M01, only the following relationships remained of interest: • Polymer stock level score with audit overall quality (rho=0.494 n=13 p=0.086), service

level (rho=0.611 n=13 p=0.027), display for self-selection (rho=0.542 n=13 p=0.056) and the combined quality score (rho=0.485 n=13 p=0.093)

• Alginate stock level score with audit overall quality (rho=0.743 n=13 p=0.004), service level (rho=0.618 n=13 p=0.024) and display for self-selection (rho=0.592 n=13 p=0.033

• Zinc paste bandage stock level score with the average appropriateness rating (rho=0.530 n=12 p=0.077)

• Total stock level score with audit overall quality (rho=0.652 n=13 p=0.016) and service level (rho=0.520 n=13 p=0.069)

The mystery shopper score became negatively correlated with the stock level score of foams (rho=-0.563 n=13 p=0.045). Sales /purchase history data were not compared to quality measures as there were too few data points

8.3.3.3 Human and information resources

As the number of pharmacy assistants with any wound care training increased, the audit overall service level rating, the appropriateness of products sold and the combined quality score increased (Table 8.38 and Figure 8.50). Similar relationships between quality measures and number of recently trained assistants were seen. The proportion of pharmacy trading hours when wound care trained pharmacy assistants were on duty was not related to any quality measure.

Table 8.38 Spearman’s correlations between quality measures and staff training as reported by the proprietor

Mystery shop Audit Stat-istic Rank Score Overall

qualityService

level Space

& facility




Comb-ined

quality score

rho 0.218 0.016 0.470 0.540 0.361 0.208 0.843 0.379 0.630 p value 0.495 0.960 0.123 0.070 0.248 0.516 0.001 0.224 0.028

No. assistants with any wound care training

N 12 12 12 12 12 12 11 12 12 rho 0.219 0.119 0.615 0.595 0.429 0.244 0.628 0.520 0.586 p value 0.517 0.727 0.044 0.054 0.188 0.470 0.052 0.101 0.058

No. assistants with recent wound care training N 11 11 11 11 11 11 10 11 11

rho -0.028 -0.014 0.195 0.204 0.167 -0.005 0.316 0.093 0.167 p value 0.935 0.967 0.565 0.547 0.624 0.989 0.343 0.787 0.624

% of opening hours when wound care trained staff member on duty

N 11 11 11 11 11 11 11 11 11

rho -0.451 -0.335 -0.443 -0.425 -0.086 -0.350 0.000 -0.656 -0.540p value 0.141 0.287 0.149 0.168 0.791 0.265 1.000 0.021 0.070

No. pharmacists with wound care professional development in last 2 years

N 12 12 12 12 12 12 11 12 12

rho -0.455 -0.359 -0.473 -0.478 -0.137 -0.391 -0.043 -0.695 -0.588p value 0.138 0.252 0.121 0.116 0.672 0.208 0.900 0.012 0.045

% of all pharmacists with recent training N 12 12 12 12 12 12 11 12 12

97

For the number of assistants with any wound care training, excluding M01 meant that only the relationship with the average appropriateness rating remained significant (rho=0.788, n=10, p=0.007). The number of pharmacists undertaking wound care professional development in the last 2 years was not related to audit quality measures, the mystery shopper visit or the appropriateness of products sold, however, the greater the number of pharmacist and the percentage of pharmacists with recent wound care training, the lower the independent and combined quality scores (Figure 8.50). Note that the benchmark site did not respond to this question.

No. wound care trained assistants

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Figure 8.50 Combined quality score versus A. number of pharmacy assistants with

training and B. number of pharmacists undertaking wound care professional development in the last 2 years

Lack of information resources in the pharmacy to refer to for wound care assessment was tended to be related to a higher mystery shopper score (p=0.070), however the benchmark site reported not having such resources, and when M01 was excluded from the analysis, the relationship was no longer of interest. The availability of information resources for staff on product selection and its appropriate use was not related to any quality measure, however M01 reported not having such information. After excluding M01, the two remaining sites without these resources (M05 and R05) had a significantly lower average appropriateness rating of products sold (median no=1 and median yes=1.5, p=0.044).

8.3.3.4 Policies and procedures maintained

Patient wound care records were kept by 4 of 11 pharmacies responding to the question (M01, M06, M08, R01), and these sites were associated with significantly higher mystery shopper rank (p=0.014) and score (p=0.044), more appropriate products sold (p=0.032) and a higher combined quality score (p=0.059) (Figure 8.51). All relationships remained of interest (p<0.1) after the exclusion of M01 except for the combined quality score. The percentage of the 11 different policy types that each pharmacy had as a written policy was not correlated with any quality measure, nor was the percentage of policies that were unwritten. The existence of a policy or procedure (written or unwritten versus no policy, whether considered relevant or not), as reported by the proprietor, was not related to any quality measure for any policy or procedure type.

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Figure 8.51 Boxplots of keeping patient wound care records versus Mystery shopper A.

Rank and B. Score, and C. Average appropriateness of products sold and D. Combined quality score

8.3.4 QUIZZES

The results of the quizzes were compared with each of the quality measures. Neither the mean quiz score per site for pharmacy assistants nor the proportion of respondents reporting wound care training were related to any quality measure (Table 8.39 and Figure 8.52). Excluding M01, where a single assistant of 6 EFT pharmacy assistants responded to the quiz, the relationship between audit overall quality rating and pharmacy assistant quiz score became more important (rho=0.589, n=10 p=0.073) as did the relationship between the percentage of respondents with wound care training and the mystery shopper rank (rho=0.565, n=10 p=0.089) and audit service level rating (rho=0.565, n=10 p=0.089).

Table 8.39 Spearman’s correlations between quality measures and quiz scores and assistants estimates of persuading customers to purchase a more appropriate product

Mystery shop Audit Quiz variables Stat-istic Rank Score Overall

qualityService

level Space

& facility




Comb-ined

quality score

rho 0.050 -0.105 0.280 0.160 -0.082 0.245 -0.061 0.219 0.196 p value 0.883 0.759 0.405 0.639 0.810 0.468 0.867 0.517 0.563

Pharmacy assistants Mean score for Q1+2 N 11 11 11 11 11 11 10 11 11

rho 0.263 0.213 0.231 0.296 0.254 0.115 -0.044 0.268 0.268 p value 0.434 0.529 0.494 0.377 0.452 0.736 0.905 0.426 0.426

% of PA respondents with wound training

N 11 11 11 11 11 11 10 11 11

99

Table 8.39 continued Mystery shop Audit Quiz variables Stat-

istic Rank Score Overall quality

Service level

Space &

facility




Comb-ined

quality score

rho -0.055 -0.273 0.604 0.506 0.354 0.786 0.046 0.341 0.268 p value 0.880 0.445 0.064 0.136 0.316 0.007 0.906 0.334 0.454

Pharmacists Mean score for Q1+2 N 10 10 10 10 10 10 9 10 10

rho 0.122 0.047 0.730 0.817 0.488 0.670 0.471 0.689 0.622 p value 0.737 0.898 0.017 0.004 0.153 0.034 0.201 0.028 0.055

Pharmacists Mean score Q3

N 10 10 10 10 10 10 9 10 10 rho 0.176 0.037 0.829 0.855 0.503 0.766 0.494 0.745 0.673 p value 0.627 0.919 0.003 0.002 0.138 0.010 0.177 0.013 0.033

Pharmacists Mean % total score (Q1+2+3) N 10 10 10 10 10 10 9 10 10

rho 0.000 0.084 0.217 0.333 0.667 -0.012 -0.228 0.119 -0.048p value 1.000 0.843 0.606 0.420 0.071 0.978 0.588 0.779 0.911

Mean of Assistants estimates % of customer persuaded

N 8 8 8 8 8 8 8 8 8

P'cy assistant mean quiz score

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Figure 8.52 Pharmacy assistant quiz score versus A. audit overall quality rating, B.

combined quality score and C. average appropriateness of products sold, and percentage of quiz respondents reporting wound care training versus D. Mystery shopper rank and E. audit service level rating

The pharmacist quiz scores were related to audit quality measures and the independent and combined quality scores (Table 8.39 and Figure 8.53). The appropriateness of products sold and the mystery shopper visit was not related to pharmacist wound care knowledge as tested by the quiz.

100

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Figure 8.53 Pharmacist percentage correct of total quiz score versus A. audit overall

quality rating, B. independent and C. combined quality score

The pharmacy assistants estimates of the percentage of wound care customers they had influenced to make a more appropriate purchase was only related to the audit rating of a display to aid self-selection (Table 8.39). Surprisingly, as the display was better suited to aid self-selection, assistants believed they had been more persuasive.

8.3.5 CUSTOMER LOG

Information on wound seen at the community pharmacy was obtained from pharmacist estimates via the wound care profile, pharmacy assistant estimates via the quiz and the presentation recorded on the customer log. Higher pharmacy assistant estimates of the percentage of customers who purchase of products for future use were associated with lower ratings of overall quality, service level and display to aid self-selection at audit (Table 8.40). Higher proprietor and pharmacy assistant estimates and actual presentation of burns were associated with higher quality ratings across a range of measures. For cuts and grazes, proprietor and pharmacy assistant estimates had opposite relationships with the mystery shopper score; as the proprietor estimated percent of customers presenting with cuts and grazes increased, the mystery shopper score increased, where as the score decreased as assistant estimates increased. Although not significant, as the percentage of logged customers with cuts and grazes or purchasing products for future use increased, nearly all of the quality measures declined (negative correlation coefficients).

Table 8.40 Spearman’s correlations between quality measures and wound types seen as reported by the proprietor, pharmacy assistants and on the customer log

Mystery shop Audit Wound types % of wound care customers


qualityService

level Space

& facility




Comb-ined

quality score

rho -0.355 -0.281 -0.009 -0.171 -0.419 -0.356 0.243 -0.143 0.069 p value 0.284 0.403 0.978 0.615 0.199 0.282 0.471 0.675 0.840

Profile – none, for future use

N 11 11 11 11 11 11 11 11 11 rho -0.052 0.101 -0.601 -0.661 -0.557 -0.660 -0.524 -0.331 -0.374p value 0.894 0.795 0.087 0.052 0.119 0.053 0.147 0.385 0.321

Pharmacy assist-ants - none, for future use N 9 9 9 9 9 9 9 9 9

rho -0.047 0.034 -0.077 -0.209 -0.403 -0.404 0.024 -0.168 -0.067p value 0.879 0.912 0.802 0.494 0.173 0.171 0.939 0.584 0.828

Log - none, for future use

N 13 13 13 13 13 13 13 13 13

101

Table 8.40 continued Mystery shop Audit Wound types

% of wound care customers


qualityService

level Space

& facility




Comb-ined

quality score

rho 0.687 0.636 0.026 0.165 0.146 0.213 -0.037 0.438 0.278 p value 0.014 0.026 0.937 0.609 0.650 0.507 0.910 0.154 0.382

Profile – burns

N 12 12 12 12 12 12 12 12 12 rho 0.288 0.232 0.564 0.695 0.881 0.460 0.298 0.492 0.390 p value 0.452 0.548 0.114 0.038 0.002 0.213 0.436 0.179 0.300

Pharmacy assist-ants - burns

N 9 9 9 9 9 9 9 9 9 rho 0.119 0.000 0.531 0.523 0.050 0.225 0.660 0.445 0.603 p value 0.699 1.000 0.062 0.067 0.872 0.461 0.014 0.127 0.029

Log - burns

N 13 13 13 13 13 13 13 13 13 rho 0.211 0.058 0.428 0.413 -0.134 0.120 0.625 0.352 0.500 p value 0.510 0.859 0.166 0.182 0.678 0.710 0.030 0.262 0.098

Log – burns, excluding M03

N 12 12 12 12 12 12 12 12 12 rho 0.397 0.577 0.230 0.190 0.136 0.079 -0.140 0.394 0.175 p value 0.201 0.050 0.472 0.554 0.673 0.807 0.664 0.205 0.586

Profile – cuts & grazes

N 12 12 12 12 12 12 12 12 12 rho -0.525 -0.601 0.239 0.186 0.220 0.085 0.111 -0.203 -0.085p value 0.146 0.087 0.535 0.631 0.569 0.828 0.777 0.600 0.828

Pharmacy assistants - cuts & grazes N 9 9 9 9 9 9 9 9 9

rho -0.220 -0.156 -0.076 -0.155 0.135 -0.173 -0.457 -0.198 -0.386p value 0.469 0.611 0.805 0.614 0.660 0.573 0.116 0.516 0.193

Log - cuts & grazes

N 13 13 13 13 13 13 13 13 13 rho 0.384 0.277 0.513 0.525 0.018 0.161 0.264 0.600 0.508 p value 0.243 0.410 0.107 0.097 0.957 0.636 0.432 0.051 0.111

Profile – leg ulcers or pressure sores N 11 11 11 11 11 11 11 11 11

rho -0.360 -0.093 0.139 0.100 -0.092 0.151 -0.214 0.017 -0.126p value 0.342 0.811 0.721 0.797 0.814 0.698 0.580 0.966 0.748

Pharmacy assist-ants - leg ulcers or pressure sores N 9 9 9 9 9 9 9 9 9

rho -0.156 -0.427 -0.050 -0.131 -0.379 -0.247 0.451 -0.241 -0.017p value 0.612 0.145 0.872 0.671 0.201 0.416 0.122 0.429 0.956

Log - leg ulcers or pressure sores

N 13 13 13 13 13 13 13 13 13 rho 0.330 0.187 0.119 0.226 -0.130 0.171 0.453 0.186 0.386 p value 0.321 0.582 0.727 0.504 0.703 0.616 0.161 0.584 0.241

Profile – stitches or surgical wounds N 11 11 11 11 11 11 11 11 11

rho 0.317 0.279 0.076 0.150 0.333 -0.427 0.134 0.150 0.200 p value 0.406 0.468 0.847 0.700 0.381 0.252 0.731 0.700 0.606

Pharmacy assist-ants - stitches or surgical wounds N 9 9 9 9 9 9 9 9 9

rho -0.115 0.028 -0.187 -0.143 0.148 0.074 -0.493 -0.115 -0.236p value 0.707 0.928 0.540 0.641 0.629 0.809 0.087 0.707 0.437

Log - stitches or surgical wounds

N 13 13 13 13 13 13 13 13 13 rho 0.254 -0.061 -0.153 -0.145 -0.441 0.128 0.624 0.017 0.356 p value 0.509 0.876 0.694 0.710 0.235 0.742 0.073 0.965 0.347

Profile – other wounds

N 9 9 9 9 9 9 9 9 9 rho -0.647 -0.558 0.687 0.393 0.317 0.523 -0.147 -0.013 -0.178p value 0.083 0.150 0.060 0.335 0.444 0.183 0.729 0.976 0.674

Pharmacy assistants - other wounds N 8 8 8 8 8 8 8 8 8

rho 0.354 0.139 -0.010 0.094 -0.198 0.253 0.421 0.139 0.277 p value 0.236 0.652 0.974 0.761 0.516 0.405 0.152 0.651 0.359

Log - other wounds

N 13 13 13 13 13 13 13 13 13

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Higher proprietor estimates of the percentage of customers with leg ulcers or pressure sores were associated with higher audit service level and independent quality score, where as correlations between leg ulcer/pressure sore percentages from the customer log and the quality measures tended to be negative, although not significant. Estimates of customers with stitches or surgical wounds were not related to any quality measure but as the percentage of logged customers with stitches or surgical wound increased, the appropriateness of products sold decreased. The appropriateness rating of products sold increased as the proprietor estimates of the percentage of other wounds increased while higher assistant estimates were associated with higher audit overall quality but a lower mystery shopper rank. Since the customer log for M03 was suspected to be incomplete, correlations were repeated excluding M03. Only relationships for the percentage of customers with burns and audit quality measures differed, in that the probability of correlation was <0.1. Excluding M03 made no appreciable difference to the interpretation of the relationships between quality measures and the percentage of customers per the log seeking wound care products for future use, cuts and grazes, leg ulcers or pressure sores, stitches or surgical wounds and other wound types. Quality measures were also compared to the percentage of the various dressing categories sold per the log, and the percentage of dressings sold that were not passive or first aid dressings, tapes or other dressings (Table 8.41). There was a trend towards increased sales of film dressings (sold by 12 of 13 sites) to be associated with a decline across all quality measures. The negative correlation between mystery shopper rank and sale of foams seen after M03 was excluded was due to the sale of 2 Lyofoam products to a single customer at a single site, which represented 25% of products sold in 2 weeks. The positive correlation between hydrocolloid sales and audit, appropriateness and combined quality measures was due to sales of hydrocolloids at only 2 sites, both of which having a more advanced service. The explanation for the relationships between quality measures and polymer and alginate dressings is the same (only 2 sites selling either category of dressing in 2 weeks). Six sites sold any hydrogels in the 2 weeks of the customer log, and higher sales were associated with higher quality score across a range of measures. Higher sales of cadexomer iodine (sold by 3 sites) was associated with higher average appropriateness of products sold and a higher combined quality score. Higher percentage sales of passive dressings was generally associated with lower quality scores (negative correlation coefficients) with the effect being significant for the average appropriateness of products sold. After M03 was excluded, the relationship between higher sales of passive dressings and lower combined quality score was also significant. Increased sales of simple first aid products also showed a trend towards decreased quality ratings (predominantly negative correlations). Excluding M03 did not appreciably affect relationships between other dressing categories and quality measures. The higher the percentage sales of dressings that were more than just passive or first aid dressings or tapes or other dressings, the higher the average appropriateness score for dressings and the combined quality score. After excluding M03, similar relationships with two of the audit measure were also of interest.

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Table 8.41 Spearman’s correlations between quality measures and percentage of dressing categories sold in 2 weeks

Mystery shop Audit Dressing types % of dressings sold in 2 weeks


qualityService

level Space

& facility




Comb-ined

quality score

rho -0.264 -0.230 -0.142 -0.196 -0.419 -0.207 -0.011 -0.187 -0.185p value 0.383 0.449 0.643 0.521 0.154 0.497 0.971 0.540 0.546

Films

N 13 13 13 13 13 13 13 13 13 rho -0.450 -0.459 0.044 -0.124 -0.443 -0.394 0.323 -0.201 -0.007p value 0.123 0.115 0.887 0.685 0.130 0.183 0.282 0.510 0.983

Foams

N 13 13 13 13 13 13 13 13 13 rho -0.516 -0.473 0.150 -0.044 -0.404 -0.353 0.317 -0.175 -0.004p value 0.086 0.121 0.641 0.892 0.193 0.261 0.315 0.587 0.990

Foams excluding M03

N 12 12 12 12 12 12 12 12 12 rho 0.262 -0.022 0.578 0.578 0.314 0.438 0.631 0.472 0.577 p value 0.387 0.942 0.038 0.038 0.295 0.134 0.021 0.104 0.039

Hydrocolloids

N 13 13 13 13 13 13 13 13 13 rho 0.621 0.496 0.461 0.578 0.251 0.377 0.629 0.609 0.777 p value 0.023 0.084 0.113 0.039 0.408 0.204 0.021 0.027 0.002

Hydrogels

N 13 13 13 13 13 13 13 13 13 rho -0.105 -0.241 0.333 0.333 0.131 0.499 0.263 0.166 0.210 p value 0.733 0.429 0.266 0.266 0.670 0.082 0.386 0.588 0.492

Polymers

N 13 13 13 13 13 13 13 13 13 rho 0.262 -0.022 0.578 0.578 0.314 0.438 0.631 0.472 0.577 p value 0.387 0.942 0.038 0.038 0.295 0.134 0.021 0.104 0.039

Alginates

N 13 13 13 13 13 13 13 13 13 rho 0.350 0.093 0.273 0.403 0.194 0.310 0.639 0.350 0.559 p value 0.241 0.762 0.367 0.172 0.526 0.303 0.019 0.241 0.047

Cadexomer iodine

N 13 13 13 13 13 13 13 13 13 rho -0.445 -0.331 -0.036 -0.138 0.071 0.091 -0.650 -0.220 -0.467p value 0.128 0.270 0.908 0.654 0.817 0.768 0.016 0.471 0.108

Passive dressings

N 13 13 13 13 13 13 13 13 13 rho -0.385 -0.319 -0.256 -0.386 -0.119 -0.053 -0.751 -0.385 -0.664p value 0.217 0.313 0.422 0.215 0.713 0.871 0.005 0.217 0.018

Passive dressings excluding M03 N 12 12 12 12 12 12 12 12 12

rho 0.249 0.326 -0.575 -0.428 -0.116 -0.464 -0.229 -0.252 -0.208p value 0.412 0.277 0.040 0.145 0.706 0.110 0.451 0.407 0.495

Simple first aid

N 13 13 13 13 13 13 13 13 13 rho 0.088 -0.118 0.421 0.405 0.071 0.298 0.788 0.280 0.489 p value 0.775 0.702 0.151 0.170 0.817 0.324 0.001 0.354 0.090

% of dressings sold that were not passive, 1st aid, tapes or other dressings

N 13 13 13 13 13 13 13 13 13

rho 0.084 -0.107 0.554 0.540 0.161 0.372 0.818 0.378 0.552 p value 0.795 0.740 0.061 0.070 0.618 0.234 0.001 0.226 0.063

As above but excluding M03

N 12 12 12 12 12 12 12 12 12 The involvement of the pharmacy staff in the product selection made by a customer was classified in terms of influencing choice and changing choice. Pharmacies where a greater percentage of customers had their choice influenced had higher quality ratings for two audit measures and the average appropriateness of products sold (Table 8.42). The latter relationship remained significant after M03 was excluded. Actually changing customer choice was associated with higher levels across more of the quality measures, most of which remained

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significant after M03 was excluded. Similarly, as the proportion of customer episodes in which the pharmacist was consulted increased, so too did audit quality measures and the independent quality score. Interestingly, consultation with the pharmacist was not related to the average appropriateness of products sold (Figure 8.54). Excluding M03 did not appreciably change these relationships, nor the relationship between the percentage of customers referred on and any quality measure, none of which were significantly related to the extent of referral.

Table 8.42 Spearman’s correlations between quality measures and influences on customer choice, pharmacist consultation and referral onto another health professional

Mystery shop Audit % of customers with valid log record


qualityService

level Space

& facility




Comb-ined

quality score

rho -0.225 -0.233 0.540 0.482 0.253 0.196 0.609 0.313 0.429 p value 0.459 0.445 0.057 0.095 0.405 0.522 0.027 0.297 0.144

Influenced customer choice

N 13 13 13 13 13 13 13 13 13 rho -0.077 -0.183 0.421 0.347 0.056 0.018 0.642 0.217 0.329 p value 0.812 0.570 0.173 0.269 0.863 0.957 0.024 0.499 0.297

Influenced customer choice excluding M03 N 12 12 12 12 12 12 12 12 12

rho 0.412 0.292 0.584 0.542 0.131 0.485 0.416 0.627 0.579 p value 0.162 0.332 0.036 0.056 0.669 0.093 0.157 0.022 0.038

Changed customer choice

N 13 13 13 13 13 13 13 13 13 rho 0.291 0.224 0.559 0.562 0.418 0.537 0.135 0.549 0.407 p value 0.334 0.462 0.047 0.046 0.156 0.058 0.660 0.052 0.168

Pharmacist asked

N 13 13 13 13 13 13 13 13 13 rho 0.089 0.181 0.081 0.001 -0.243 0.074 -0.269 0.098 -0.081p value 0.772 0.555 0.792 0.996 0.424 0.810 0.375 0.751 0.793

Referred on

N 13 13 13 13 13 13 13 13 13

% log episodes pharmacist consulted

120100806040200-20

Ave

. app

ropr

iate

ness

ratin

g

2.6

2.4

2.2

2.0

1.8

1.6

1.4

1.2

1.00.8

R08R07

R06

R05

R04

R02

R01

M08

M06

M05

M04

M03

M01

% log episodes pharmacist consulted

120100806040200-20

Ave

. app

ropr

iate

ness

ratin

g

2.6

2.4

2.2

2.0

1.8

1.6

1.4

1.2

1.00.8

R08R07

R06

R05

R04

R02

R01

M08

M06

M05

M04

M03

M01

Figure 8.54 Percentage of customer episodes in which the pharmacist was consulted

per the customer log versus the average appropriateness of products sold in the 2 week period

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9. DISCUSSION Currently in Australian community pharmacy, the nature of wound care service provided is extremely varied. Services can range from one where pharmacies provide a simple wound dressing (or first aid products like Bandaids®) from a limited, low-turnover range without seeking information about the type of wound, to one where a detailed history is taken as part of providing an optimal local dressing (with supporting patient information about appropriate use of the dressing) from a well stocked product range. Service quality should be a concern for providers and consumers irrespective of the level of wound care service offered. In this pilot study, we attempted to measure aspects of a wound care service that relate to service quality. This wound care benchmarking pilot study has led to a number of ‘firsts’. While wound care is a service expected by community pharmacy customers (Ortiz, Ledin et al. 1987), the nature of that service has never before been described, nor has a ‘best practice’ model been developed. Although benchmarking has been used in wound care (pressure ulcer prevention) across hospitals (Bankert, Daughtridge et al. 1996), it has not been used for wound care in community pharmacy, where a broad range of wounds are seen. The use of a multidisciplinary ‘expert panel’ methodology to develop indicators for Australian community pharmacy practice is also novel.

9.1 STAKEHOLDERS IN WOUND CARE – MEMBERSHIP OF THE EXPERT PANEL

Since perceptions of quality depend on the differing perspectives of various stakeholders, a number of experts and stakeholders were identified and approached to participate on an expert panel for Phase 1. Specific expertise was required about wound care (e.g. what indicates quality-in-fact), pharmacy practice (e.g. the feasibility of operationalising possible indicators), the possibilities of electronic data collection from primary (e.g. Point of sale and dispensing data) and secondary sources e.g. wholesaler data. Likely stakeholders were felt to be: • Community pharmacists and staff of community pharmacies. • Consumers. • Other health professionals including medical practitioners and community nurses. • Expert individuals and groups e.g. Wound Education and Research Group, Consumer

groups e.g. Diabetes Australia. • Manufacturers of wound care products, wholesalers, pharmacy IT developers, pharmacy

banner groups. The Pharmacy Guild and Pharmaceutical Society of Australia were approached for input into indicator development since the organisations had a stake in the project as it relates to QCPP and best practice standards. The Commonwealth and State Governments were likely to be stakeholders in the benchmarking project as it relates to accountability but also in the most appropriate use of dressings, that in some instances are funded by governments either directly as a subsidy or indirectly e.g. funding of a community nursing service providing wound care. The expert panel for this project included representatives of all of the stakeholder groups identified above except state and commonwealth government, banner group and wholesaler representatives. Expanding the expert panel to include such representatives may have added different perspectives to the indicator development process but an all-inclusive expert panel needs to be balanced against the need to conserve resources, and the added difficulties of

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working with a larger group. We opted for a smaller working party because it was also anticipated that some of the views of government, banner groups and wholesalers might be gained from other panel members, e.g. manufacturers, pharmacists and pharmacy IT representative could highlight issues related to wholesalers. If the expert panel methodology for indicator development was extended into other areas of pharmacy practice, membership on the panel would need to reflect stakeholders in the specific practice area (Appendix E).

9.2 DEFINING WOUND CARE IN COMMUNITY PHARMACY Service quality indicators need to reflect the nature of the service being provided. As highlighted in 1.1, the nature of wound care service in community pharmacy has not been explored in the literature. Thus the first activity for the expert panel was to define the important elements of a community pharmacy wound care service, that were necessary for a pharmacy to provide appropriate products in a way that ensured the appropriate and beneficial use of the product provided. The panel discussions highlighted that both technical and functional quality1 need to be considered in describing a best practice service. From the viewpoint of a wound care expert, making a proper wound assessment and providing the most appropriate dressing was important. Often this viewpoint was based on the premise that a customer should seek advice. While the consumers agreed that the provision of the ‘best product’ was important, the need to inform consumers was also considered as central. The informational component of a service should give the customer the choice to self-select and still get good wound care, or to seek advice. The provision of information on appropriate use of products, once they were selected was also important from a consumer perspective (and from wound care expert perspective). The best practice flow diagram for a customer encounter was developed by the investigators (JS, GD and SC) to include the technical quality and part of the functional quality aspects of a generic best practice wound care service. Provision of information to aid self-selection was not addressed in the flow chart. The flow chart was reviewed by panel members, some of whom made suggestions for minor changes that were subsequently addressed. Expert panels have been used to develop protocols for wound care but predominantly for chronic wounds and mainly linked to a hospital or clinic setting (Bankert, Daughtridge et al. 1996; Harding, Cutting et al. 2000). The flow diagram is intended to be a broad wound care best practice model for community pharmacy and so attempts to cover all contingencies for how to deal with different customer needs. The detail for processes, such as assessing infection risk, would need detailed explanatory documentation for use in various practice settings. At this stage, we have only identified what the steps are and the fine detail would be determined later, and possibly tailored to each pharmacy site, based on resource availability. The flow diagram is not in itself a clinical pathways document but could link into one very easily. It is multidisciplinary in its approach and is patient focused – i.e. what specific structural and process needs there are for customers in this wound care practice. The multidisciplinary

1 Functional quality’ refers to perceptions by the consumer about how a service is delivered (e.g. prompt, friendly service). ‘Technical quality’ refers to perceptions by the consumer about what is received from the service (e.g. the correct medication, counselling) Holdford, D. and R. Schulz (1999). "Effect of technical and functional quality on patient perceptions of pharmaceutical service quality." Pharmaceutical Research 16(9): 1344-1351.

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approach needs to recognise the roles of other health professionals in wound care. For example, taking a history and making an assessment of a wound is in the context of product supply (appropriate product supplied with directions for appropriate use) rather than diagnosis, and the flow diagram incorporates lots of referral points. In Figure 5.1, the "recommend appropriate treatment" box could lead into a clinical pathways flowchart eventually so that this process supports not only the path of the customer through the pharmacy but aids in treatment or clinical decision making. Such pathways would be similar to those developed in the recent study by the Wound Education and Research Group at Monash University, “Wound Healing and Cost Impacts of Interventions by Pharmacists in Community Settings”. The level to which a community pharmacy provides a wound care service is a decision for each pharmacy. This decision would be based, in part, on the available resources (including human resources), the customer base and availability of other wound care services in the locality, and the owners’ interest in wound care and their views as to the appropriate service level to provide. At the present time, pharmacies do not know where the level of the service they offer is in relation to ‘best practice’. The flow diagram gives pharmacies the opportunity to examine their practice to see how each step of the model is addressed and to put practices in place to achieve a good quality service, irrespective of the service level (basic, intermediate or advanced).

9.3 CHARACTERISTICS OF COMMUNITY PHARMACY WOUND CARE SERVICES

Through the drop out of city and smaller pharmacies, the pharmacies involved in the pilot study did not reflect national patterns despite there being a better match at time of recruitment. Lower service quality sites may be under-represented in the pilot (7.1) as indicated by the screening visit. Larger and strip pharmacies were over-represented while banner group pharmacies were under-represented compared to the national pattern (nationally, 70% of pharmacies are smaller than 200m2, 54% are strip locations and 43% are in banner groups (unpublished national census data)(7.1). Although none of the sites were more remote than PhARIA category 3, the percentage of in PhARIA 1 pharmacies in the pilot matches the percentage of Victorian pharmacies in PhARIA 1. Pharmacies taking part in this pilot study had a higher rate of QCPP accreditation (77%) than national pattern where recently, about 3200 of approximately 5000 Australian community pharmacies have been accredited (Quality Care Pharmacy Program 2003). The greater commitment to quality among the pilot sites may be reflected by the willingness of these sites to stay in the pilot study.

9.3.1 PHARMACY CHARACTERISTICS, STAFFING AND WORKLOAD

The distribution of opening hours of pharmacies in the pilot was similar to that of Victorian pharmacies overall (median from unpublished census data of 55 hours/week, mean of 60.4 hours/week). Many of the pharmacies in the pilot study opened late or for extended hours over the weekends, thus offering primary care for anyone seeking wound care attention outside the weekday 9am-5pm period. By and large the number of prescriptions filled was related to total pharmacist hours, suggesting that a main pharmacist activity was dispensing. The majority of pharmacies employed two pharmacists to cover the opening hours. The metropolitan pharmacies, however, tended to have more pharmacists to cover the pharmacy hours (Figure 8.16), possibly because there were more part-time pharmacists available in city. It is also possible that the simple calculation of total pharmacist hours (opening hours + hours where more than 1 pharmacist on duty) does not represent full pharmacist hours, when, for example, there are 3 or more pharmacists on duty.

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Additional pharmacists may have been doing duties other than dispensing since the 2 of the pharmacies with the lowest pharmacy hours:pharmacist ratio also had links to residential care. Future studies may need to explore the impact of fragmentation of pharmacist hours on wound care service provision. The number of prescriptions dispensed did not relate to the number of EFT pharmacy assistants employed, however there was a trend towards pharmacy assistant numbers increasing with increasing shop size (Figure 8.15), reflecting a higher staff need when a greater area of the pharmacy was front-of-shop.

9.3.1.1 Wound care human and information resources

Pharmacist and pharmacy assistant wound care knowledge and beliefs were examined using a short quiz that investigated beliefs about referral and wound healing and aspects of product knowledge. Overall, scores for questions 1 and 2, asked of both pharmacy assistants and pharmacists, were close to the maximum score of 18 but there were certain patterns of response about appropriate referral that were of concern (Table 8.8): Most pharmacists would expect staff to refer a small sore of 1 week’s duration to the

pharmacist (as did staff) but 15% would not have expected a moderately large burn on a child to be referred to them by pharmacy assistants.

Almost 10% of pharmacy assistants would not refer a chronic leg ulcer to a pharmacist, but continue to supply Melolin (perhaps related to the mystery shopper experience, 8.2.1). Pharmacy assistants beliefs about wound healing (i.e. a scab is good) may be behind this lack of referral

These sites might benefit on guidelines that indicate when a pharmacy assistant should consult the pharmacist. Pharmacists performed less well when more detailed wound care knowledge was explored using a short answer format, in particular for questions about the more unusual dressings and identifying risk factors for delayed healing. These results suggest that pharmacists might benefit from additional product training (both selection and use of dressings) and wound assessment. The current study is consistent with the findings of Sussman (Sussman 1998) who reported on a self-assessment test of pharmacists’ knowledge of wound management and noted that there was a need to increase knowledge about wound management. Quiz scores did vary across the sites and interestingly, when the pharmacists scored well, the pharmacy assistants were also likely to perform well. In 2 sites, assistants performed better than the pharmacists. Most pharmacies had at least one pharmacy assistant with wound care training, and the proprietor indicated that training tended to be recent (Figure 8.19). Training reported by pharmacy assistants was not in concordance with proprietors reports. Over 11 sites, the number of trained staff was only in concordance at 4 sites (the proprietor overstated the number compared to staff reports at 3 sites and understated the situation at 3 sites, and did not know the number of trained staff at 1 site). For 9 sites were number of assistants and those assistants with training were known, of the total 36 assistants, proprietors reported that 22 (61%) had had wound care training. For the same sites of the 23 respondents to the pharmacy assistant quiz, 11 (48%) reported any wound care training (Table 8.11). The recency of the training may also be less than that reported by proprietors – of the 12 pharmacy assistants describing their training, only 5 reported training within the last 2 years. The quality of the reported training was also extremely varied. Thus when the proprietor reported that wound care-trained pharmacy assistants were on duty for 50% of the pharmacy opening hour, this may overstate the situation

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considerably. The majority of sites would not readily be able to detect these anomalies since only two sites kept written procedures about training requirements or maintaining current knowledge (Table 8.7). Proprietors reported that pharmacists at one third of sites had received no recent wound care training in the previous 2 years. Interestingly, the rate of recent pharmacist wound care training seemed to be higher in rural pharmacies than metropolitan sites, despite the potentially easier access to training for metropolitan pharmacists. Training tended to be more formal professional development activities. Recent pharmacist training was not related to the number of trained pharmacy assistants, as reported by the proprietor, suggesting that pharmacists and assistants did not attend the same type of training and had different training opportunities. According to the post-pilot interviews, pharmacy assistants also have different training needs from pharmacists (7.3) with pharmacy assistants reporting that currently available training was often ‘over our heads’ and it was not presented in a way that could be incorporated into their practice - service protocols and tools were felt to be preferable. Protocols and tools for wound care could certainly be helpful. Thomas called for a wound care formulary as a means to promote appropriateness and manage expenditure (Thomas 1995). Decision trees to aid product selection were found to be helpful to improve product selection and chronic wound treatment by community nurses (Pieper, Templin et al. 1999). Such protocols and tools must, however, recognise the sometimes low level of skill and expertise of the user in terms of the complexity and detail of the content i.e. tools should be pitched at the right level so that they will actually be used by pharmacy assistants. Access to training was another issue, especially for rural sites or those with a low turnover of wound products, who where not always able to take part in the education provided by manufacturers’. As the expert panel pointed out (7.4), lack of suitable training may well be contributing to a lack of confidence among assistants to deal with customers seeking wound care (7.3). In addition to building confidence, training is worthwhile to build knowledge since assistants who reported wound care training scored better on the quiz (Figure 8.21), and reported persuading more customers to purchase more appropriate wound care. Training should be directed towards both pharmacists and assistants as their roles and needs are different but together, they form a team. Calls for more wound care training for pharmacists are common in commentary articles about wound care in pharmacy (Peard 2003) and in studies (Sussman 1998), but training for pharmacy assistants is also needed since a recent study by Smith and Nephew found that three quarters of wound care consumers surveyed had spoken to the pharmacy staff in the store (Peard 2003). The current study suggests that while words may have been exchanged, this was unlikely to routinely be an exchange of information and advice. Another barrier for quality wound care services is that information resources about wound assessment and product selection/use for staff use were not always readily available, and certainly, the information resources cited would not always be suitable for use by pharmacy assistants e.g. the Australian Pharmaceutical Formulary or PSA lecture materials (8.1.2.4). Six of the sites also used manufactures’ materials. This reliance on the manufactures’ may be behind the call for unbiased, independent information made by sites during the post-pilot interviews (7.3) and the expert panel (7.4 and Appendix C). Currency of information is also a potential concern. While all sites had at least one information resource that was less than 2 years old, pharmacists reported that it was difficult to keep up with all the new products

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(Appendix C), and only 2 sites had written procedures about maintaining the currency of wound care resources (Table 8.7).


Accommodating a wound care display in a community pharmacy is clearly a challenge. These items are bulky, taking up a lot of shelf space but they are often low turnover items. The location of the wound care display is a balance between the amount of shelf space required and the need to have these items close to the dispensary and other professional areas. Often, the more wound care stock held, the further the section was from the dispensary (8.1.1.1). The shelf space allowed for dressings and the relative amount occupied by wound dressings depended on the size of the pharmacy and whether the pharmacy was metropolitan or rural (Table 8.1). Excluding the benchmark site, rural pharmacies have more dressing shelving than city pharmacies. Larger pharmacies had more dressing shelves but in rural pharmacies, the shelves were more likely to be filled with first aid products compared whereas the larger city pharmacies (mostly more advanced sites) filled the extra shelving with wound care products (Figure 8.3). The arrangement or merchandising of wound care products is a problem for community pharmacies (7.3) and most pharmacies attempt to overcome this problem by using manufacturers’ shelving or display aids (8.1.1.1). No site successfully mastered the display of wound care products. Perhaps the manufactures’ displays better met the needs of pharmacies with smaller displays because these pharmacies tended to use manufactures’ displays to a greater extent than sites with larger amounts of stock. Alternatively, low shelf space may indicate low interest in wound care and using manufactures’ displays might be a simple option or be associated with the best deal in buying in a general range. Despite these issues, pharmacies generally indicated that their space and facility needs were more than 50% met (median score 63) (Figure 8.18). The site with the lowest rating on space needs met was also the site most vocal about merchandising problems for wound care (Appendix C). Pharmacies also indicated that the display went a long way towards fully aiding customer self-selection of wound dressings (median score 69) (Figure 8.18). Given the emphasis placed by consumers on self-selection, it was disappointing that only 2 sites had written aids to self-selection (8.1.1.1). The lack of concordance between the pharmacists’ views and evidence of self-selection aids should be addressed if pharmacists are to more fully meet customer wound care needs. Merchandising of wound care requires further development to meet the needs of both the pharmacies and customers. Merchandising and promotion were also identified by Bruce Annabel as necessary for growth of the wound care category (Peard 2003), together with expertise and someone in the pharmacy taking ownership of the category, to sustain interest and momentum.

9.3.3 WOUND CARE PRACTICES

Wound care transactions were predominantly handled by pharmacy assistants with variable levels of pharmacist involvement (Table 8.25), supporting the contention of Bruce Annabel, that pharmacists leave wound care to “the girls” (Peard 2003). At 2 sites, the pharmacist was frequently consulted, reflecting the pharmacists’ interest in wound care or perhaps an unwritten policy. Excluding these sites, pharmacists were consulted for about one quarter of wound care customers. Thus, wound care services in most pharmacies are, de facto, provided by pharmacy

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assistants. Whether this reflects a conscious decision by these pharmacies or whether it reflects a situation where the pharmacist is ‘too busy’ is a matter of conjecture that cannot be answered by this study. What is clear is that the service is being provided by pharmacy assistants and that pharmacists may be missing an opportunity to “value add” and differentiate their value proposition relative to other retailers. Perceptions of influence on customer wound care purchases also varied. Proprietors at 90% of the pharmacies believed that customers had been persuaded to purchase a more appropriate product and pharmacy assistants estimated that overall, they had influenced the choice of about 50% of customers (Table 8.10). The customer log however, indicated that the level of influence was actually higher at 61% overall, with staff at 4 sites underestimating their influence relative to the log (Table 8.25). More wound care training for pharmacy assistants is likely to increase their ability to influence customer choice since as the number of wound care trained pharmacy assistants increased, the percentage of customers whose choices were influenced increased (8.1.7). Referral of wound care customers to other health professionals or services occurred but proprietor estimates of a median of 4 over a 4 week period (8.1.2.2), were higher than the actual referral rate indicated by the log (median 1 in 2 weeks), with 5 or 12 sites overestimating and 3 sites underestimating the referral rate (Table 8.25). About 50% of the sites also had customers referred to them for wound care. No site had any standard forms for the referral process and only two sites had procedures for deciding when to refer and one site claimed to have a written procedure on how to refer (although 5 reported an unwritten procedure) (Table 8.7). The majority of the sites did, however have knowledge of other wound care providers in their area (8.1.2.4) but in all but one case, this was not documented. About one third of proprietors reported taking detailed wound histories but these were rarely documented (8.1.2.2 and 8.1.2.5). Three quarters of sites reported that there was an opportunity to monitor wound healing progress with about two-thirds of these sites reporting they actually monitored progress. No site had any forms to record wound monitoring and review (8.1.2.5) and only 2 sites had unwritten procedures for monitoring wound progress; the rest had no policies or procedures and one site considered these to be irrelevant. Just over 60% of pharmacies had written information available for customer to take away but again, there was a reliance on manufactures’ materials with over 60% of the sites typically providing manufacturers’ pamphlets. Data on how frequently written information was provided was not collected in this study but since only one site had written procedures on advising customers on the appropriate use of products (Table 8.7), the effectiveness of counselling using the written materials might be called into question.

9.3.3.1 Type of wound seen and products provided

According to the two-week customer log, about one third of wound care customers sought treatment for cuts and grazes while about 20% had stitches or surgical wound, 15% had burns and 12% had leg ulcers or pressure sores requiring wound care (Table 8.23). These data cannot be compared to the literature, as no such prevalence data has been published. Indeed information about the prevalence of wounds and injuries in the community is sparse and mainly collected about more severe wounds or injuries that resulted in hospital admissions or emergency visits or formal injury notification (Fife, Barancik et al. 1984; Shanon, Bashaw et al. 1992; Parker, Carl et al. 1994; Williams, Furbee et al. 1995; Small 2000) and others have called

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for prospective studies to determine injury prevalence (Shanon, Bashaw et al. 1992). The customer log completed in this pilot is a form of prospective data collection about the prevalence of wounds seen in community pharmacies. Estimates by the proprietor and the assistants of the types of wound seen in each pharmacy were a poor reflection of wounds actually seen in that pharmacy in a 2 week period (Table 8.28). While the 2 week window might be too short to provide the most reliable picture, the fact that staff and proprietor estimates did not correlate with each other suggests that to get a realistic measure on which to plan wound care services, pharmacies should collect actual, prospective data on customer wound types and products supplied. This is particularly important since the lack of functionality of pharmacy POS systems for this audit purpose limits using sales/purchase data for service planning (7.3). Sales history data was considered to be the most difficult to compile by the majority of the pharmacies involved in the pilot study, and few sites actually provided this information, therefore sales analyses were based mostly on the 2 week customer log, providing yet another reason to carry out this prospective data collection. For the wounds seen in the 2-week period, over a quarter of all products supplied were passive dressings with a further 17% of products being tapes or bandages. Simple first aid products accounted for a further 12% of products sold and 10% were dressing-related products such as antiseptics. Thus overall, only 35% of products sold in the 2 weeks were more advanced wound care dressings. This rate was consistent the overall percentage of dressings sales per quarter that were advanced dressings sold by the 5 sites providing sales data (average 36% , range 14-72%) (Table 8.18). The advanced dressings sold per the log (foams, alginates, hydrocolloids and hydrogels, etc,) were more consistently given a higher appropriateness rating as a facilitator of wound healing and there was little difference between sites for the appropriateness ratings for these products. Appropriateness ratings for passive dressings, first aid products, other dressing related products and tapes and bandages sold were more varied overall and between the sites. In short, where a passive or first aid dressing was supplied, it was probably not very appropriate as an aid to wound healing. There is clearly a need to improve the appropriateness of products sold when the median appropriateness ratings per product was a score of 1 out of a range of –1 to 3, equivalent to “Limited potential to help healing (Table 8.27). The sale of wound care products generally represents a relatively small percentage of total turnover for pharmacies with about 70% of pilot sites reporting that their turnover from wound care was less than 2% of total turnover. The percentage of turnover from wound care increases, however, as the proportion of products sold in the 2 weeks of the log that were more advanced dressings increased (Figure 8.24). Thus selling more advanced dressings could increase the contribution of this category to turnover. Pharmacies with a higher turnover from wound care also had more shelf space for dressings and more of it was occupied by wound dressings as opposed to first aid products, tapes and bandages. Changing the stock holdings, however, is unlikely to change turnover without other service components being in place (e.g. trained staff, and a wound care service commitment).

9.3.3.2 Stock holdings

Actual quantities of stock could not be determined from the stock form because different sites reported the quantities in different ways, suggesting that improvements are required for the stock holdings form. The data provided by the audit, however, was a validation of the stock

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holding data and was collected more consistently. The stock range and stock level scores generated from the audit data were used in stock level analyses. The community pharmacies in the pilot study all carried considerable quantities of multiple brands of passive and first aid dressings, in multiple sizes (Table 8.2 and Table 8.14). Film dressings were the type of interactive dressing most commonly stocked. Film dressings could be considered only the next step up from passive dressings as a technological advance (although appropriate for a range of wounds) (Table 8.2). Hydrocolloid dressings have more advanced features than film dressings and so might require more knowledge and confidence to ‘sell’ these dressings to customers. While all pharmacies had at least some stock of hydrocolloid dressings, the stock range and level were not as high as for film dressings. There was ‘therapeutic duplication’ i.e. different brands of essentially equivalent products mainly for passive and film dressings (Table 8.15) indicating sites carried more stock than was necessary to meet the need for passive and film dressings. Other advanced and sometimes more specialised dressings were not stocked by all pharmacies (Table 8.3). Surprisingly, there was one site that did not carry a hydrogel dressing despite promotion of these products to consumers (e.g. recent commercials for Bandaid Healing Gel) for common conditions like chickenpox. Stocking only a narrow range of advanced dressings possibly reflects a number of concerns raised by the expert panel at their second meeting (See 7.4 and Appendix E). There is a lack of knowledge about wound healing and the use of advanced products and therefore a lack of confidence among pharmacy assistants and some pharmacists. This means that staff are not able to persuade customers to try better but more expensive dressings. Limited customer awareness that something more than gauze exists is another barrier. Gauze is still a popular choice among Australian consumers (Peard 2003) yet there is much evidence that it can impede healing, make dressing changes painful, and for chronic wounds, actually increase costs (Ovington 2001). So if there is limited demand for the advanced products, it is not surprising that most pharmacies only keep limited stocks. Educating all consumers about wound care is beyond the role of community pharmacies but pharmacies have the opportunity to provide informal education at each request for wound care products. A larger stock range and a higher stock level was associated with higher percentage of turnover from wound care (8.1.4.2). This relationship was driven by greater stock levels of the more interactive, advanced dressings. The percentage of turnover from wound care was not related to stock holdings of passive or first aid dressings. However, while passive dressings represent about 35% of stock held (Table 8.14), these dressings represent about 65% of products sold – while advanced dressings can be widely stocked, they turnover less often. So for advanced dressings to have an impact on turnover, it is not just enough to stock them, they must be sold. Such a change may well require the pharmacy to change its focus and to upskill pharmacy assistants. Another approach to the stock holding issue would be to better match stock holdings with needs (as indicated, for example, by the customer log) rather than sales. For example, rather than supplying a passive dressing for a large graze of the elbow for that customer who fell off their bicycle, suggest using an adhesive hydrocolloid product. Despite the potential lack of demand for more advanced products from customers, proprietors indicated that sales or sales history were only secondary considerations in determining stock range, although sales/demand was the main factor considered when it was time to review the range carried (8.1.2.3). The most common primary factor determining the stock carried was advice from the manufacturers’ or their representatives, with support from the manufacturer being another secondary consideration in deciding just what range was carried. Advice from the representatives was also cited as a factor when it came to reviewing the stock range carried.

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Thus the influence of the manufacturer was strong in stock decisions and so modifying the message from the manufacturer is a potential area for intervention to improve stock holdings. Despite all 12 responding pharmacies reported making changes to the stock range they carried in the previous 12 months, only 2 sites had written policies or procedures about maintaining appropriate levels of dressing products from relevant categories (Table 8.7). Again, lack of a procedure criteria for review is an issue, particularly where pharmacists find it hard to keep track of different and new products (Appendix C).

9.3.3.3 Customer survey

Collecting health outcome data has become an imperative in healthcare, and in wound care, the main outcome of interest must be wound healing. The low level of customer recruitment by pharmacies for the customer survey (Table 8.19), a mechanism to capture outcomes (wound healing and satisfaction) was therefore disappointing, despite proprietors recognising the need to monitor and record wound care outcomes (Appendix C). Barriers such as time pressures, the staff’s perceptions of a customers willingness or ability to participate and perhaps fear of rejection meant that those pharmacies that did recruit any customers were selective in the customers they approached to recruit, rather than recruiting consecutive customers. The paperwork involved in carrying out the consenting process, as required by ethics committees, was also cited as a barrier. Conducting a customer survey can be time-consuming, and to reduce the burden on the pharmacies and to reduce acquiescence bias, the research team decided to limit pharmacy involvement to recruitment. The telephone survey was conducted by the researchers. Some pharmacists suggested that a better result might have been obtained if the pharmacies themselves had followed up on wound healing outcomes, for example, at subsequent pharmacy visits (Appendix C). This is certainly a strategy that might be adopted should the benchmarking be used as a form of self-audit by pharmacies. Pharmacies conducting a self-audit would not necessarily have access to independent researchers to conduct the survey. While the customer survey does not appear to be a useful indicator as implemented in the pilot study and only nine customers (8 of whom use that pharmacy “almost always”) were surveyed from 6 pharmacies, certain aspects of the information derived from the few interviews is informative (8.1.6): In keeping with the customer log and sales data, most products used were passive products

and tapes and bandages. Perhaps related to the product supplied, most customers reported changing the dressing at

least daily at some point in the healing process. Based on customer recall, advice was given 55% of the time. Low levels of advice were

also reported by our mystery shoppers (8.2.1). This lack of advice might explain the need identified by one customer for a brochure or written instructions for later reference (from a site indicating that such information was available).

Pharmacists were involved in the interaction about 78% of the time, in contrast to the 25% rate from the customer log, perhaps reflecting that regular customers well known to the pharmacy were recruited.

Customers reported that pharmacists influenced patient choices 44% of the time and assistants influenced choice 33% of the time (compared with 44% for the hospital, doctor or nurse).

Despite these issues, indicating area of low technical quality, the majority of customers rated the pharmacies as excellent in meeting their overall wound care needs i.e. high functional quality (Table 8.20).

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Even in this small sample, areas for improvement were identified. The challenge will be how to operationalise this type of survey so that this valuable customer feedback can be used by pharmacies to improve their wound care service, and hopefully, accumulate evidence on pharmacy value-adding in wound care.

9.3.4 PROPRIETORS’ PERCEPTIONS OF SERVICE QUALITY

Pharmacy proprietors or managers generally believed they were providing a wound care service that was more than halfway between poor and excellent (8.1.2.2) and most were satisfied with the wound care space and facilities they had and how well the display aided self-selection of wound dressings by customers. The lack of correlation between overall service quality and space and facility needs met and display for self-selection ratings (Table 8.5) suggest that these dimensions were not considered in the proprietors assessment of service quality. Given the emphasis of the consumer representative on the expert panel placed on being able to self-select a dressing, that pharmacists don’t considered self-selection as part of the quality domain is a concern. Like the auditor’s ratings, the proprietors’ perceptions of the extent to which space and facility needs were met did not relate to the amount of dressing shelving. The number of linear metres of wound care shelving, but not first aid shelving influenced the proprietors overall quality rating (8.1.2.2). Similarly stock range but not the quantity of stock influenced how the proprietor saw service quality. The percentage of total turnover from wound care also influenced perceptions of overall quality and service level provided (8.1.2.3). Proprietors’ beliefs about they type of wound they saw influenced their perception of quality since as the estimated percentage of wound care customers who had leg ulcers or pressure sore increased, so too did the proprietor’s overall quality rating. From the proprietor’s perspective, quality was also be related to the percentage of non-basic dressings sold (Figure 8.24). The majority of sites completed the profile after or while the customer log was being kept. The proprietor’s perception of overall service quality was also related to their beliefs about the amount and availability of pharmacy assistants with wound care training (8.1.2.4) but to a much lesser extent, assistant wound care knowledge (8.1.3). Recent pharmacist wound care training was not related to the proprietor’s perception of overall quality and the service level provided but pharmacist knowledge, as indicated by the quiz (8.1.3), was related to these proprietor quality ratings.

9.4 INDEPENDENT MEASURES OF SERVICE QUALITY By and large, pharmacies did not perform well in the single mystery shopper visit. Pharmacies performed so badly in fact, that a planned assessment of the quality of information seeking and advice given could not be done, since so few of these events occurred. The scenario was a direct product request and the work from the QCPP Support Centre suggests that pharmacies generally perform more poorly for this type of request, whereas they perform much better for a symptom based request (Quality Care Pharmacy Program 2003). However, since service quality is a multidimensional concept, covering such tangibles as the physical environment, the availability of stock and the timeliness of the service as well as intangibles like the content and appropriateness of the service and how the service was delivered, multiple measures of quality were used in the pilot study. In the pilot study, the indicators collected were largely about structure and process (Sidani and Braden 1998), and to a lesser extent, since the customer survey was ineffective, outcome. To examine which indicators were related to quality,

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indicators were compared to seven independent assessments of aspects of service quality. These measures covered various domains of the broad concept of service quality: The mystery shopper score emphasised information seeking and advice by the pharmacy

assistant (or pharmacist) as part of the service experience. It did not attempt to assess the appropriateness of any advice. The mystery shopper rank included some of the same aspects as the score but also extra, intangible aspects of the shopping experience, such as being ignored by nearby assistants when the shopper was at the wound care section, or a display of reluctance when a receipt was requested.

The auditor’s perception of service quality were largely based on how the wound care section looked, the stock carried, aids to customer self-selection and how space and facilities appeared to meet the needs to the pharmacy. The auditor rated quality overall, the service level provided (rudimentary to advanced), how well space and facility needs were met for the level of service provided, and how well the wound care display aided self-selection by customers.

How appropriate products sold in a 2 weeks period were likely to be in facilitating wound healing. Is the pharmacy selling the most appropriate dressing to a customer?

From these measures, two additional scores were generated. The independent quality score combined the auditor’s overall quality assessment, the mystery shopper rank and the mystery shopper score with a weighting of 2:1:1. This score was really related to the shopping experience i.e. perceived or functional quality. The second score, the combined quality score, combined the auditor’s overall quality assessment, the mystery shopper rank, the mystery shopper score and the appropriateness of products sold with a weighting of 2:1:1:2, thus including technical quality in this measure. A limitation of these calculations was that the validity of some of the measures was not fully explored: The scoring of the mystery shopper report and the effectively equal weighting the

components were not confirmed by consumers and other stakeholders. The inter-rater reliability of the auditor ratings was not tested, although a single rater

assessed all sites, and some of the auditor ratings correlated with mystery shopper ranks. The correlation of the independent score, however, with all the mystery shopper and audit ratings suggests convergence validity for the approach, as does the correlation of the combined quality score with 6 of the 7 quality measures, including appropriateness of products sold (8.2.2). The customer survey also provided some limited corroboration of the quality scores. When combined quality score of the sites included in the pilot was considered, pharmacies could be classified into 4 groups, sub-basic (sites scoring less than 30 and in urgent need of improvement), sites offering a basic service (scores between 30 and 45 although site R07 might act as an appropriate benchmark here or be a member of the next service level group), an intermediate service group (scores 45-75) and a single site offering a more advanced service (score >75) (Figure 9.1). While the pharmacy wound care expert on the expert panel also considered that there were three service levels in community pharmacy, his view was that no sites were truly providing an advanced service (Appendix E).

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0

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M11 R04 R08 M05 R06 M08 R07 R02 R05 R01 M03 M04 M06 M01

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Figure 9.1 Classification of service level based on the combined quality score

9.5 INDICATORS LINKED TO SERVICE QUALITY Each indicator was compared to 9 quality measures. Some indicators influenced some aspects of service quality, for example, impressions of how the wound care area looked but not the technical quality of the service provided as demonstrated by the appropriateness score. It is also important to recognise that there are common underlying concepts that potentially explain some relationships, such as the pharmacies commitment to wound care may underlie the decision to sign the area “wound care” rather than “first aid”. Another limitation of this pilot work is that the small sample size increases the chance that a real relationship between quality and a potential indicator is missed (Type II error) while considering relationships with probablities of up to 0.10 increased the change of Type I error (saying a relationship exists when it is false). Another limitation of the indicators is that not all the data reported by pharmacies were independently audited, e.g. number of staff. There is also the possibility that other indicators of service quality were not measured in this pilot study, so that those indicators found to be related to quality in this pilot study should be considered a minimum set rather than a complete list. It is also possible that a some type of algorithm might be developed incorporating indicators to model quality. Such multivariate modeling was not possible in the pilot study since the number of cases is likely to be smaller than the number of variables in any model.

9.5.1 PHARMACY CHARACTERISTICS, STAFFING AND WORKLOAD

All quality measures were independent of pharmacy size (large versus small) (8.1.1.2 and 8.3.1), suggesting that the provision of a quality wound care service may not depend on pharmacy size. The story is less clear cut for rural versus metropolitan pharmacies -while there was no difference on quality measures overall (8.1.1.2 and 8.3.1), after excluding the 3 more advanced wound care pharmacies, (all metropolitan), there were trends towards rural pharmacies having higher median audit, independent and combined the median combined quality scores than the remaining metropolitan pharmacies. One possible explanation for this trend is that rural pharmacies have a greater service gap to fill than metropolitan pharmacies.

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Rural customers cannot always go somewhere else close by for wound care services. The greater stock level and range carried by rural pharmacies in the study (Figure 8.5) supports this notion. The role of rural pharmacies in wound care in their communities requires further investigation as the finding of higher service quality in the country might also be explained by selection bias. In this small study, banner group membership was related to only one quality measure. Being in a banner group actually had a negative effect on pharmacy performance at the mystery shopper visit (8.3.1) possibly because banner group pharmacies tend to be larger and so may have been more busy at the time of this single visit). This banner group effect needs further study with repeated shopper visits and a larger sample. A commitment to quality as indicated by QCPP accreditation was only associated with audit quality measures about space and facilities and display aiding self-selection, in short, the ‘visual’ component of the service. QCPP accreditation had no effect on the mystery shopper visit or the appropriateness of products sold, possibly because the program does not explicitly address technical quality in the wound care category. Accredited pharmacies should not solely rely on meeting QCPP standards to improve wound care service. Other actions are needed to improve quality, such as staff training, and such activities can be easily integrated into the QCPP program. The size of the business entity was related to the audit quality scores, the independent quality score and combined quality scores as indicated by relationships with total number of opening hours (Figure 8.42) and the number of prescriptions filled per week (Figure 8.43), since in Australian community pharmacies, opening hours and number of prescriptions dispensed are highly correlated with shop size and turnover (unpublished data). The quality indicators that were of interest here were related to observational aspects of the service, such as the size of the wound care display (8.1.1.2). Larger business entities may have more resources (e.g. space and staff) to spend on display-related aspects of the service. The service dimensions measured by the mystery shopper visit and the appropriateness of products sold were independent of the business entity size related measures, so that both small and larger pharmacies have the potential to perform well on these measures. Other key pharmacy characteristics related various independent quality assessments include: The number of EFT pharmacists did not relate to any quality measure but the number of

pharmacists (irrespective of whether full-time or part-time) was related to audit quality measures and the independent and combined quality scores probably since these figures were also correlated with pharmacy business size.

Total pharmacist hours per EFT pharmacist was not related to any quality measure The number of EFT assistants was only related to audit overall quality ratings, again

probably as part of the relationship to size. These relationships suggest that staffing levels are only indirectly related to quality. Service quality may be related to how busy staff are at the time of the service episode (as implies by some of the mystery shopper visits) so that further investigation of service delivery during the busiest and quietest times in pharmacies is needed. Providing wound care products to other corporate customers i.e. aged care facilities and community nursing were likely to be related to quality in this small sample, since three of the more advanced sites provided this extra service dimension. This indicator, however, is more likely to represent a proprietor decision to be more active in wound care, rather than being a direct cause of higher service quality.

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A number of indicators of the layout of the wound care section were related to quality measures, which is not surprising since the auditor’s assessments were based largely on how the wound care display looked, the size of the display and the volume and range of stock, and the independent and combined quality scores included an auditor’s rating in their calculation. A potentially good indicator for customers of the kind of wound care service the pharmacy offers is what is written on the sign for the area. When the sign says ‘wound care’, there is a broader stock range (Figure 8.6) and better auditor ratings for how well space and facility needs were met, how well the display aids self-selection and trends for better ratings of service level and overall quality (8.3.2). The choice of signage between ‘wound care’, ‘first aid’ and no sign, may well reflect the philosophy of the proprietor about the importance of wound care in his or her practice. It is important to note that it is not the linear metres of shelving of product per se (which is more related to pharmacy size and total turnover), but to the proportion of wound care verus first aid/passive dressings shelves that were related to quality measures (8.3.2 and 8.1.1.2). The decision to emphasise wound care rather than first aid in a display may reflect a proprietor’s ‘commitment to value-add’ in this area. The appropriateness of products sold was higher there the amount of shelf space occupied by wound care products was higher and where the pharmacist had to walk from the dispensary to the wound care section, probably a reflection of the bulk/dimensions of wound care products and difficulty in merchandising the category. Some pharmacies had addressed some merchandising issues in the arrangement and display of stock and had higher quality scores (Figure 8.40) but use of manufacturer’s shelving aids was not related to quality (8.3.2). It is likely that pharmacies where some thought has been given to overcoming the problems inherent with the display of wound care products are also likely to have given attention to other areas of wound care service delivery, and despite the suggestion of Gai Leslie (Peard 2003), use of manufacturers’ displays is not always the answer.

9.5.3 WOUND CARE PRACTICES

Some wound care practices are clearly associated with service quality. A number of sites had customers referred to the pharmacy by other health professionals for wound care services, suggesting that these other health professionals perceived that the pharmacy offered a superior service. This was found to be the case with those pharmacies receiving referrals providing, on average, more appropriate dressings (Figure 8.47). Similarly, keeping patient wound care records was associated with higher quality scores in 4 of the 9 measures (8.3.3.4). It was surprising that a number of other wound care-related practices (availability of written information for customers, referrals to other health professionals, wound history taking and monitoring) that might be expected to be related to quality were not (8.3.3.1). The lack of association between monitoring and quality was particularly surprising because one would expect that the act of monitoring might indicate a greater commitment or focus on wound care in a pharmacy. There are several possible explanations for these findings: The indicator about written information only asked about its availability, not how often it

was provided. The quality measures may not have tapped into the monitoring aspect of a higher level

service. The interpretation of what constitutes “monitoring” by respondents was varied and, since

the “monitoring’’ was somewhat unstructured, the effect of monitoring was not as expected

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i.e. some sites did not perform effective monitoring of progress (in a pharmaceutical care process), considering a question like “How is that wound going Mrs Jones…”, without additional probing questions (or an examination) to be monitoring.

Indicators were based on proprietor reports, not on objectively or prospectively collected information on the actual frequency with which each activity took place. Proprietor’s reports of assistants persuading customers to select a more appropriate product were at odds with the findings from the customer log where relationships were seen between quality and extent of customer influence (Table 8.42).

The customer log further supported the role of pharmacy assistants in promoting a quality wound care service. The more frequently a pharmacy assistant influenced or changed customer product selection, the better the pharmacy performed across a range of levels, including technical quality as indicated by the appropriateness of products sold (Table 8.42). The greater involvement of the pharmacist in a customer wound care episode was also associated with higher functional service quality (audit measures and the independent quality score) but not technical quality (average appropriateness of dressings sold) (Figure 8.54). Two possible reasons for the lack of pharmacist influence on the appropriateness of products sold are: That pharmacists are being consulted too infrequently, and so do not have the opportunity to

value-add by influencing the customer to purchase a more appropriate product That when the pharmacist is consulted, they do not influence the customer’s purchase. Lack

of wound care knowledge and/or confidence and lack of time (e.g. pressures of prescription work) may well be barriers to pharmacists value-adding in a wound care transaction.

If the former is the case, pharmacies might benefit from defined procedures where triggers for pharmacist consultation are clearly identified (such as in the flow chart developed for this project). Pharmacist education and the availability of appropriate tools, and a change in work flow or priorities might minimise the latter problem. The lack of relationship between pharmacist wound care knowledge (as tested by the quiz (Table 8.39)) and appropriateness of products sold, however, suggests that increasing pharmacist wound care knowledge is not a stand-alone strategy to sell more appropriate wound care products. The lack of written policies and procedures about wound care is not unique to community pharmacy – in one US study of home health agencies, 56% had no written policies or procedures about wound care (Pieper, Templin et al. 1999). In this community pharmacy pilot study, the actual benefit of existence of procedures, either written or unwritten is unclear, a concern when a number of recommendations arising from this pilot are related to formalising procedures. In this study, the presence of policies or procedures relating to wound care practices and maintenance of resources was not related to any quality measure (8.3.3.4). Again, the actual existence and, more importantly, the use of policies or procedures was not collected for the pilot, merely the proprietor’s report, not actual procedures followed by staff. It may have been helpful to validate these reports by asking pharmacy assistants whether such policies or procedures existed. This would also give an indication as to how well a procedure was recognised by staff, because a procedure will not be effective unless it is widely known by staff and the importance of following procedure is emphasised by the proprietor. The implementation of tools or procedures arising from this project must take into account these success factors. The frequency with which wound care activities are actually performed provides more useful quality improvement information than estimates. Wound care practices need to be more formalised, with simple and consistent methods for documentation. The customer log used in the pilot study could be adapted to collect information on the provision of written information

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about wound care. Pharmacies should record each occasion on which wound healing progress was monitored. Such documentation would also allow pharmacies to report on the outcome of their wound care service. A common methodology/procedure and documentation format for monitoring and outcome recording should be developed so that the information from many different pharmacies can be aggregated i.e. so that sites monitoring wound care outcomes use the “same ruler”.

9.5.4 HUMAN AND INFORMATION RESOURCES

Training in wound care and the effects on service quality were interesting and seem to reflect the fact that pharmacy assistants have a significant role to play in the service provision. As the number of pharmacy assistants with any wound care training increased, the audit overall service level rating, the appropriateness of products sold and the combined quality score increased (Table 8.38). Assistants with training also scored better on the knowledge quiz (8.1.3) and there was a relationship between audit overall quality rating and pharmacy assistant quiz scores in a given pharmacy (8.3.4). Training pharmacy assistants is likely to be a worthwhile investment for proprietors who wish to begin to improve their wound care service. The proportion of opening hours that wound care trained staff were on duty was not related to quality but proprietors may benefit from matching the times at which wound care-trained staff are on duty with the peak times that customers with wounds present. This type of mismatch was identified by one proprietor in the study (Appendix E). The influence of pharmacist training on quality can be seen indirectly. Recent pharmacist wound care training (within the last 2 years, as reported by the proprietor) not related to any quality measures, but while the influence of any pharmacist wound care training was not assessed, the quiz findings suggest that increasing pharmacist knowledge may also increase quality in some areas (Table 8.39). The presence or absence of information resources for staff to refer to about wound care assessments was not related to service quality, but pharmacies that had information resources to help staff with product selection and appropriate product use did sell more appropriate wound care products (8.3.3.3). This finding supports the calls of pilot participants (7.3) and the panel (7.4) for tools to help pharmacy assistants guide customers in appropriate product selection and use.

9.5.5 TYPE OF WOUND SEEN AND PRODUCTS PROVIDED

Information on wounds seen at the community pharmacy was obtained from pharmacist estimates via the wound care profile, pharmacy assistant estimates via the quiz and the presentation recorded on the customer log. Pharmacies that estimated and saw (per the log) a higher number of burns presentations to the pharmacy achieved higher quality ratings across a range of measures. Sites with higher percentages of stitches and surgical wounds has the lowest appropriateness scores for products sold, which may also reflect product recommendations from doctors, nurses or hospitals performing the surgery. Just because a product has been recommended by another health professional, it does not mean that the product is the most appropriate - a number of studies have demonstrated deficiencies of nurse knowledge of wound care and appropriate use of products (Pieper, Templin et al. 1999) while others have suggested that “not all physicians, nurses and therapists have knowledge of the broad array of products available and understand they way they work” (Ovington 2001). In the customer log, a number of entries indicated that the passive dressings provided (for stitches and surgical wounds, and cuts and grazes) were base of a doctor’s advice to the customer.

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Quality measures were also compared to the percentage of the various dressing categories sold per the log, and the percentage of dressings sold that were not passive or first aid dressings, tapes or other dressings. Pharmacies selling a greater proportion of passive dressings, first aid dressings, and to a lesser extent, film dressings generally scored lower on the quality measures (Table 8.41). So conversely, the higher the percentage sales of dressings that were more than just passive or first aid dressings or tapes or other dressings, the better a pharmacy performed on a range of quality measures. This suggests that to improve wound care service quality, pharmacies need to work to change their sales emphasis, or since dressings are “bought not sold”, to actively promote and sell more advanced dressings. Such a strategy would require development for the staff to increase product knowledge and to help staff turn a direct product request for a passive dressing into an opportunity to sell a more appropriate product by seeking more information from the customer about the wound. Since sales of some classes of more advanced dressings were associated with several quality measures, namely, hydrogels, hydrocolloids and alginates, focusing on these particular areas may be a starting point. There may be an opportunity for manufacturers to tailor programs or marketing to support such targeted sales initiatives.

9.5.6 STOCK AND SALES

Pharmacies with a higher percentage of turnover from wound care products score higher on 6 of the 9 quality measures (8.3.3.2) suggesting that to increase turnover from this category, pharmacies need to concentrate on improving service quality by “value-adding” to the purchase of a wound care product. Part of this “value-adding” relates to the stock range and level carried both of which were related to quality measures(Table 8.36 and Table 8.37). Having a broad range of products was one of the steps identified by Bruce Annabel as being necessary to generate growth in the wound care category (Peard 2003). This advice should be tempered the finding of extensive therapeutic duplication i.e. multiple brands of essentially the same dressing (often passive dressings) being carried by some pharmacies (Table 8.15). Passive and first aid dressing stock range and level scores were not related to any quality measure because all sites carried these items (as indeed to supermarkets). The presence and level of stock of some of the more specialised dressings (e.g. polymer, alginate, foam and hydrofibre dressings, and zinc paste bandages) were markers for higher quality ratings, possibly because the sites stocking these items have a greater focus on wound care. Just stocking more advanced dressings is not going to increase service quality – stock range and stock level score of hydrogels and hydrocolloids were not associated with quality measures, however sales of these items were associated with quality (9.5.5). As mentioned earlier, tailoring stock holdings to the type of wound seen and to the types of products provided (realising that people were provided passive dressings in many instances when there was something more appropriate) may help rationalise stock holdings will improving merchandising as suggested by Bruce Annabel and Gai Leslie (Peard 2003). In the absence of effective POS information, the customer log is a good tool to capture the information on which to make such stock holding decisions. The benefit of the log for this purpose was recognised by a number of sites (Appendix E).

9.5.7 PROPRIETORS’ PERCEPTIONS OF SERVICE DELIVERY AND QUALITY

A proprietor’s beliefs about the resources and practices related to the wound care services provided by his or her pharmacy were not found to be reliable measures (Table 8.28 and sections 9.3.1.1 and 9.3.3). Prospective and or quantitative information on demand, resources

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and current practices is, therefore, a better basis for quality improvement than the proprietor’s “gut feel”. The same can be said for functional quality. The proprietors’ perceptions of the service quality provided by his/her pharmacy was not related to the functional quality measure of customer experience (as indicated by the mystery shopper visit) or the perceptions of an independent auditor. Proprietors were better able to estimate the technical quality aspects of their service, as indicated by the appropriateness of dressings sold, which did increase with the proprietor’s perception of overall quality (Table 8.34). Proprietor dissatisfaction with extent to which they had met the space and facility needs for wound care was also related to higher technical quality, i.e., proprietors already providing a higher quality service had higher expectations about what they could do, and so were dissatisfied with their current space and facilities. This dissatisfaction, emphasised by the attention the pilot forced the proprietor to give the issue, may well be a driver for further improvement.

9.6 WOUND CARE – AN UNMET NEED IN THE COMMUNITY While there is little data available on the prevalence of wounds in the community, available data for western countries suggest that wounds, including cuts, scrapes/abrasions and lacerations are quite common, and that even relatively minor wounds are associated with morbidity such as infection and loss of function (and possible loss of earnings), as indicated by the following literature reports: “Wounds account for approximately 23-30 percent of the total workload of an A&E

[Accident & Emergency] department” (Small 2000), with the most common types being lacerations from blunt trauma, then cuts, abrasions and burns. The most common serious complication from a simple laceration was wound infection.

In a study of work injuries in adolescents found that an estimated 2% of all working students had injuries that resulted in more than 3 days of limited activity and at least some missed work with sprains and strains being the most common cause (38%) followed by cuts and lacerations (24%) and burns (13%) (Parker, Carl et al. 1994). Lacerations/cuts were generally not so severe but burns accounted for 36% of hospitalisations from injuries.

Based on 8177 visits to emergency departments in Ohio, the overall annual rate for injuries was 194/1000 residents of North-eastern Ohio, of these 194, 28 were caused by a cut, 8 were animal bites, 6 were caused by a foreign body and 3 from hot or corrosive fluid (Fife, Barancik et al. 1984).

In a review of non-fatal childhood injuries resulting in a visit to a children’s hospital eastern Ontario, most visits were for minor injuries (bumps, swellings, cuts, bruises and scrapes) and only 4% actually admitted to hospital (mostly motor vehicle accidents). Of the 28886 charts reviews, 21%of children had cuts, 2.4% had scrapes and 2.2% had burns (Shanon, Bashaw et al. 1992).

An estimated 0.2-1% of developed countries populations were reported to be affected by lower extremity leg ulcers with venous insufficiency (Marston, Carlin et al. 1999).

There are many reports that demonstrate that appropriate use of more advanced dressings versus simple or no dressings is cost effective for a range of wound types, whether the setting be for inpatients, at an outpatient clinic, in long term care facilities or domiciliary nursing services (Dorman, Moffatt et al. 1995; Bolton, Van Rijswijk et al. 1996; Hermans and Bolton 1996; Phillips 1996; Price 1999; Kerstein and Gahtan 2000; Ovington 2001; Meaume and Gemmen 2002; Capasso and Munro 2003; Kerstein 2003). In these settings, greater proportion of patients have more severe or chronic wounds compared to wound care customers in community pharmacy. Cost-effectiveness was often largely due to savings in nursing time. No studies were found that showed cost effectiveness for types of wound seen in community pharmacies

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where patient is often their own care-giver so that little nursing time is involved. There is an opportunity for community pharmacy to provide evidence of cost-effectiveness. This pilot study attempted to collect information on wound outcome to explore such issues but this part of the pilot study was not successful. Use of appropriate and often more advanced dressings can bring many benefits to patients such as (Dorman, Moffatt et al. 1995; Hermans and Bolton 1996; Ovington 2001): Less frequent, often easier dressing changes, less associated pain and less caregiver time Less pain because nerve endings are protected Faster healing through reduced infection, reduced cooling and dehydration of the wound,

and reduced trauma to the wound bed with dressing changes Better cosmetic result with less scarring Better quality of life and reduced impact of the wound and dressing on daily living Reduced loss of productivity such as a faster return to work

Wounds among customers of Australian community pharmacies are an issue and there is potential for community pharmacy to expand into the wound care market. Recently, a pilot survey conducted by Datacol Research sought consumer views on wide ranging survey about factors affecting satisfaction with pharmacy, including the prevalence of various conditions and consumers interaction with community pharmacies related to purchases and consultation (Mearns 2003). The results were based on 290 returns from Canberra consumers. In this pilot survey, relatively minor injuries that may require wound care were quite common. Overall, 28.5% of respondents reported having a cut, wound or splinter in the last 4 week period, and this prevalence was about the same as that reported for upset stomachs or feeling nauseous and more frequent than experiencing a sprained or strained muscle (16%) or asthma (10%). Where people used wound care products (12.4% did not), half of the respondents purchased these from the supermarket but half purchased the product from a pharmacy, a pattern similar to that reported for pain relief. About 30% of respondents said that they had purchased wound care products from a pharmacy in the last 6 months, slightly less than people purchasing hay fever/allergy medicines (35%). There is potential to win wound care customers back through superior service provision and promotion/merchandising as suggested by Bruce Annabel (Peard 2003). And there is room for improvement in service delivery promoting pharmacy as a health care provider. In the Datacol survey, recognition of the pharmacy as a point of first consultation was low. To assess the likelihood of consultation with the pharmacy, respondents (a doctor, a pharmacist or someone else) for each of 15 symptoms or problems. A chronic wound situation “A sore on the lower leg that will not heal” was included in a list of 15 situations where respondents were asked to indicate who they would consult first, and only 8% of respondents indicated that they would consult a pharmacist first (other choices were “doctor” and “someone else”), compared to 2% for a chronic cough or severe stomach pain, 15% for persistent indigestion, 28% for migraine headache and 60% for diarrhoea. From these preliminary findings, it appears that customers expect product supply but are ambivalent about the “value adding” by pharmacists as a health provider, possibly because they have not experienced pharmacists acting in this role connected with wound care. Further, as the quiz results and the mystery shopper experiences suggest (Table 8.8 and section 8.3), pharmacies may not be set up to deal with chronic wounds.

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9.7 EFFECTIVENESS OF INDICATOR DEVELOPMENT PROCESS

The ability to collect data is central to the notion of audit and benchmarking. These practices have successfully led to improvement in wound care in hospitals (Bankert, Daughtridge et al. 1996; Strawbridge and Kirke 2002). There were two main components of the indicator development/ benchmarking methodology in the present study – the expert panel activities and the pilot study. The steps undertaken are similar to steps 1 to 3 carried out in a hospital-based benchmark study (Figure 9.2) and generated benchmarking data that enabled between site comparison such as the benchmark derived from a prospective, cross-sectional prevalence survey of pressure ulcers in the work by Bankert et al (Figure 9.3).

Figure 9.2 The benchmarking process used in improving quality of prevention and

treatment of pressure sores (Bankert, Daughtridge et al. 1996)

Figure 9.3 Example of benchmarking data, showing the performance of each site on

the indicator of prevalence of hospital acquired pressure ulcers (Bankert, Daughtridge et al. 1996)

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The expert panel methodology, where the panel membership was representative of stakeholders, informed about and interested in the topic and members were committed to the project, was effective. The expert panel members spent approximately 10-14 hours of their time over the study and demonstrated commitment to the project because of their interest in the topic. The panel made valuable contributions to the understanding of what should constitute a wound care service and to the development of the best practice model. The concerns of the various stakeholders were identified, allowing the researcher to collect specific data and identify needs related to these concerns e.g. customer self-selection of wound care dressings. Through the work of the panel, the project generated new ideas about community pharmacy wound care services that have potential to provide benefit community pharmacy more widely, if these ideas are acted upon. Of the indicators collected, all were feasible and practical (Audit Commission (UK) 2000) for the majority of sites except for the customer recruitment for the customer survey and the sales/purchases history data. In this study, these data were considered the most difficult to collect and they were also the most commonly missing data items. Sites with a lot of stock also felt that stock holding data was not feasible based on the time it took to compile – effective use of POS would have reduced the time to compile this stock and sales information. Despite the time spent on recording stock information, the two data collection instruments most pharmacists felt to be beneficial were the customer log and the stock holding form. While we use a more simple categorisation method to analyse stock levels (see the Audit form in Appendix B), that would have shortened the time taken to record such stock data, it seems that the benefit to the pharmacies came from working out which dressings category each product belonged to and seeing just how much stock of each class of wound dressing they carried. Overall, pharmacies spent a median of less than 4 hours (Table 7.4) to collect the data they provided, excluding customer survey recruitment) and as such, the cost in terms of time would be small and many sites reported benefits from the mere process of collecting the data using the tools provided. The relationships between potential indicators and quality measures is shown in Table 9.1. This table also shows the sources of the various data with those marked (R) being reported by proprietors. A number of these proprietor estimates were found not to be reliable in that they were not in concordance with other measures of the same variable. As mentioned earlier, proprietor perceptions and estimates need to be replaced by more objective measures or prospectively collected information. Replacing the more subjective indicators with more objective measures (e.g. instead of the proprietors estimate of the number of trained pharmacy assistants, actually using a staff training log or staff reports as the source of this indicator) will improve the validity and generalisability of the indicators. The small number of pilot sites does limit the generalisability of the findings. However, there spectrum of service quality levels was covered (while low service quality providers may have been under-represented in the pilot, 5 sites had been rated as low to low-intermediate and 6 sites as intermediate to very high basic the screening visit while 3 sites were likely to be higher service quality providers) and indicators were found to discriminate on quality. Many of the indicators found to be related to quality also suggest quality improvement actions that “may be anticipated and feasible and that are plausible in their application” (Audit Commission (UK) 2000). Those indicators found not to be related to quality measures should be retained because many are relevant to the continuous improvement process, since they also identify targets for improvement. The time input from the sites to collect data was moderate and individual pharmacies reported that, by and large, their participation in the pilot as a data collection exercise was beneficial, often in ways unanticipated by the researchers. Whether proprietors’ views would change if

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they had to put extra time into aggregating data, done by researchers in this study, is unknown. Further development of the paper tools so that data can be entered and aggregated automatically may reduce the potentially negative impact of any extra work.

Table 9.1 Relationship between indicators and any quality measure (letter in brackets indicates source of indicator data – see Key)

Related to quality measures Not related to quality measures QCPP accreditation (R) – space, facility & display

aspects only Size of business entity as indicated by: Opening hours (R) No. prescriptions filled/week (R) No. pharmacists employed (R) No. EFT Pharmacy assistants (R)

(audit aspects not service experience or technical quality) Banner group membership (A) (yes=poor mystery

shopper result)* Providing dressings to other organisations (R) Signage for the wound care area (A) Linear metres of shelving for wound care

dressings (A) and percentage of dressing shelves for wound care (not first aid) products (A) Attention to merchandising other than the use of

manufacturers’ displays (A) Wound care referral to pharmacy from other

health professionals (R) Maintenance of patient wound care records (R) Extent of pharmacy assistant influence on

customer purchase (L) Frequency of pharmacist consultation in a wound

care service episode (L) No. pharmacy assistants with wound care training

(R) Average pharmacy assistant and pharmacist

knowledge scores (Q) Presence of product selection information

resources (R) Percentage of patients seeking wound care who

had burns (R & L) and stitches/surgical wounds (L) (negative relationship) Percentage of dressings sold not passive or first

aid dressings, tapes or bandages (L) especially hydrogels, hydrocolloids and alginates Higher percentage of turnover from wound care

(R) Overall stock range and stock level (A) and stock

range and level of more specialised dressings

Rural versus metropolitan (A) but trends favour rural if exclude advanced sites* Physical size of pharmacy (A) No. EFT Pharmacists (R) Extent of use of manufacturers’ displays

(A) Total linear metres of dressing shelving (A)

and linear metres of shelving for first aid (A) Availability of written information on

wound care for customers to take away (R) Wound care referrals by pharmacy to other

health professionals (R & L) Wound history taking (R) Monitoring and follow-up of wound healing

(R) Existence of wound care

policies/procedures whether written or unwritten (R) Proportion of opening hours a wound care

trained assistant was on duty (R) Presence of wound assessment information

resources (R) Stock range and stock level of passive and

first aid dressings (A), hydrogels and hydrocolloids

Key: R=reported by proprietor; A=recorded at independent audit; L=recorded by staff on the customer log; Q=quiz; *=needs further investigation The effectiveness of the pilot study to test indicators is less clear cut because of the difficulty in recruiting a sufficient number of sites and in obtaining data for the complete set of potential indicators. Pharmacy willingness to participate in research, even a simple practice improvement

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project such as the current one, and the fact that data collection and record keeping is generally outside usual practice are barriers to the success of any indicator development project and quality improvement strategies such as audit and benchmarking. Many community pharmacies have a potentially powerful data collection and management information tool, their POS system, that is not used effectively for practice improvement, but merely as a “cash register”. An attitude change may be required before pharmacies can see value in this information, over and above immediate business needs – as one member of the research team noted “the paucity of data that can be collected from POS systems and an inability to garner data from other sources reflects the poverty of retail management skills in many pharmacies and a capacity to meander along, distracted perhaps by the incessant busyness of dispensing”. On balance, most sites did manage to compile most of the data elements and the pilot study did identify many needs, which, should they be addressed, have the potential to benefit community pharmacy more widely, suggesting that the pilot study was effective.

9.7.1 WHERE TO NEXT?

There are next steps at both the individual pharmacy level and at a the sector level. For individual pharmacies, the next step is to take action on the benchmark information sent to them. After approximately 3 weeks, the benchmarking report had been read, to varying levels of detail, by 9 of the 14 sites with 5 indicating they had identified areas for improvement and/or had plans for action (7.5). Unfortunately to the overall level of wound care service quality in community pharmacies, the sites where the report had been read and action planned tended to be in the top seven sites on the combined quality score. Perhaps this is an indication of a limitation of benchmarking, that it preaches to the converted. In this report and from the work of the expert panel, a range of steps to achieve best practice were identified (Step 4 in Figure 9.2). The fundamental question in benchmarking is ‘how does the industry leader approach a particular task compared to how we do it?’. But to improve quality these differences must be translated into action to improve. In this study, staff at the sites and the researchers completed steps 1, 2 and 3 of the Plan-Do-Check-Act continuous improvement cycle (Figure 9.4). If sites act to improve even one aspect of their wound care service (and document that they have done so or documenting that improvement was not required), this would complete the CQI loop.

Planhow to improve

the process

Do - collect data

Checkthe results

Actto standardise the change & repeat cycle

Improvement

Figure 9.4 The Plan-Do-Check-Act continuous improvement cycle (Stokes 2003)

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Areas pharmacies might identify to improve their wound care practice are pharmacy assistant training, obtaining more relevant information resources and learning about the local would care referral network, modifying the stock range carried and starting to keep wound care records including outcome documentation. There are a number of wound care documentation systems available (e.g. http://www.woundtech.com/, http://www.grane.com/woundcare.html, http://emetastar.com/WRAPalbum/) but these are largely intended for use by nurses or other health professionals as part of an advance wound care service or clinic. However, there is the potential for these tools to be adapted by, for example, a working party sponsored by pharmacy organisations. Given the findings of the mystery shopper visits and the fact that most wound care is provided by pharmacy assistants, pharmacies probably need to concentrate initially on the first part of the flow diagram, the customer interaction with the pharmacy assistant (Figure 9.5).




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

Yes

Figure 9.5 Customer – pharmacy assistant interaction – part 1 of the wound care best

practice flow diagram adapted from Figure 5.1

At the sector level, action is required to address the needs identified in the pilot such as the need for appropriate training delivered in an effective and appropriate way and simple tools, guides and protocols independent of any particular manufacturer. Further, while the study has generated a best practice flow diagram, additional supporting material needs to be developed such as minimum and best practice standards for the various levels of wound care service provision and clinical pathways for appropriate wound assessment and product selection. As an audit package, a number of materials would benefit from further development such as adapting tools for prospective and/or objective data collection and building in data aggregation tools/methodologies so that sites can aggregate their own information and see the findings more

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immediately and, if preferred, confidentially. More work is required to produce an effective method for conducting wound care customer surveys to collect customer satisfaction and wound outcome data. To continue the study as a benchmarking program, a central reporting site would be needed to collate and disseminate the benchmark results, and to promote the value of benchmarking as a quality improvement tool. A benchmarking program would also benefit from some more independent quality assessments such as an external assessment of the appropriateness of products sold and an independent audit visit, to further validate the benchmark indicators. In the longer term, mystery shopper visits might also be worthwhile, once the service standard is raised so that points of difference can be discerned.

9.8 WOUND CARE COST EFFECTIVENESS EVALUATION The assumption underpinning both self-audit and benchmarking is that action will be taken to improve service quality as the final step of the process. Assuming such action has occurred, assessing cost effectiveness of a wound care benchmarking program needs to be done at two levels: at the individual pharmacy level and at the broader, system wide level.

9.8.1 PHARMACY LEVEL

For individual pharmacies, the evaluation of cost effectiveness depends on the nature of the program (self-audit versus benchmarking). In self- audit, the indicators and quality improvement actions would be implemented and known only to the pharmacy and/or its direct customers, whereas in benchmarking implemented by a representative organisation such as the Guild, results are known more widely. In self-audit, the only impact on the pharmacy is a direct financial one as a consequence of increased turnover from the sale of wound care products or of other products arising from additional customers attracted to a perceived superior wound care service. The cost effectiveness is simply a financial calculation of the return versus the investment (e.g. the increased time required and costs incurred for training and set-up). Focusing on wound care as part of a strategy of being a specialist retail healthcare business can be financially worthwhile. In an unrelated sample of 21 pharmacies provided by Johnston Rorke Pharmacy Service, where POS category level data (some labeled wound care, others labeled first aid or first aid-sports) was available, gross profit/linear metre of shelving ranged from a low of $182 to $1,818 at site where wound care was a focus (median $409). The median gross profit return on inventory investment (GMROII) was $1.55 but at the best performing site, this figure was just over $4. The average margin for wound care type categories was 38% (range 27-52%), compared with margins for the dispensary of between 29 and 30%. By giving some focus to wound care, pharmacies can reduce their reliance on the government as a source of income. The choice between benchmarking an audit then depends on whether a benchmarking process will add more value for an individual pharmacy than simple self-assessment. Knowledge of competitors might be considered as added value or when, for example, new wound growth factors are marketed and future Guild government agreements mean that additional income can be generated from a quality wound care service.

9.8.2 HEALTH CARE SYSTEM LEVEL

From a system-wide or macro perspective, the evaluation is more formally one of cost effectiveness as the implementation of a benchmarking program needs to be assessed in terms of

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all relevant outcomes, whether affecting only the pharmacy, the immediate community, state and Federal resources, such as hospitals, etc. Firstly, quality of wound care has consequences beyond the pharmacy. A range of factors can affect the likely outcome of self care of wounds, even relatively superficial ones. First would be adequate assessment of the level of care required. Not all patients may be able to assess the consequences of simple wounds adequately and the results may be life threatening. An example would be the need for (or not) of vaccination against Clostridium tetani. Referral for further care will increase non-pharmacy costs in the short term but the cost offsets from adequate referral are large since the consequences are often hospitalisation. On the other hand, unnecessary medical consultations for trivial wounds can be avoided generating short term cost offsets. Apart from improved referral, the greatest impact of wound care quality is the actual level and quality of wound care provided. Here again the consequences extend beyond the pharmacy as infected wounds can lead to hospitalisation and even death. From the perspective of State health expenditure i.e. hospital expenditure this can be a significant cost, as it can be from a Federal perspective where the Federal government has to then subsidise the cost of antibiotics and medical services arising from poor wound management. McLaws et al (McLaws, Gold et al. 1988) did a national survey of nosocomial and community acquired infections in public hospitals and estimated that 8% of community acquired hospitalisations for infections were due to skin infections. Community acquired infections were 61% of all hospitalisations so that about 4.9% of all hospitalised infections are due to community acquired skin infections. It is not possible to accurately ascribe a cost to those infections arising from poor wound control since there are no cost data available but the consequences are likely to be fairly substantial.

9.8.3 ASSESSMENT OF THE IMPACT OF BENCHMARKING

This study’s purpose was to develop a tool to allow for quality assessment and benchmarking of pharmacy wound care. The indicators developed can be used at the individual pharmacy level or on a broader level as part of a pharmacy accreditation program. At the individual pharmacy level, the effects on the health care system are likely to be minimal unless there is widespread uptake of benchmarking. Used as a tool in, for example, accreditation or applied by some other means at the state or national level, the potential for flow on effects are much larger. Here benchmarking should raise the average standard of wound care nationally and continue to do so if applied regularly. Thus changes in, for example, wound infection rates at the national level become a more realistic probability. Since the assessment of the impact of improved wound care cannot be done by data collection at the national level, assessment would have to be conducted using standard modeling techniques such as a probabilistic model. This would be possible to construct if a trial were conducted to assess the rate of infection arising from poor wound care compared to adequate or good wound care. Alternatively a detailed clinical audit could be performed on the follow-on consequences of poor wound care and applied to an assumption based decision analytic model comparing the consequences of poor wound care versus the consequences of adequate of good wound care. Case control or cohort studies are probably not feasible. A decision analytic model was one of the original aims of this benchmarking study but on retrospect, in light of the limited data in this area isn’t feasible without at least conducting a reasonable clinical audit. A simple decision tree might be constructed if the probabilities of complications (infections usually) and whether the presence of adequate wound care made any

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difference (more importantly) were known. Some decision analytic models have used expert panels as the source of the probability information needed, however, this is not feasible for two reasons, the path of care for the average pharmacy customer with a cut or graze is unknown and even if an expert panel were to be convened, wound care is so fragmented in the community, with some customers caring for themselves, that no panel can possibly estimate probabilities and decision points. Any estimates by health professionals may well overestimate the prevalence of certain more severe outcomes or complications because this is all they see.

9.9 INVOLVING COMMUNITY PHARMACIES IN RESEARCH There were two major barriers to this study. The first was the low priority given to the research project in the face of competing imperatives – as stated by Foppe Van Mil at the Pharmaceutical Care Network Europe 3rd Working Conference in 2003, “ Pharmacists in practice will not give research a high priority” (Sanghani 2003). The second was lack of capacity to conduct research or poor understanding about what is involved in research. Both of these issues contributed to the difficulty in recruiting pharmacies and carrying out the planned data collection e.g. sales history and customer survey. The latter may well explain the former since among the pharmacies approached, there was a lot of uncertainty about what research actually meant. There was a distinct lack of understanding of the idea of describing current practice let alone measuring outcomes in research. There seems to be no culture of research participation amongst this group which would seem to be an issue that the professional associations and perhaps the pharmacy boards should consider, in any attempt to build research capacity. Many pharmacists approached indicated that they saw potential value in participating in what was essentially a practice improvement project, but were somewhat overwhelmed by the idea of being part of research and most bemoaned that they were not good enough to be in research. Strategies used to try and overcome this reluctance were: Convincing them that the study needed a genuine representation of what is happening across

all types of community pharmacy practice to be most meaningful Once they accepted that their site was a valid place to conduct research, the next task was to

convince them that the load from participating would not be great. Interestingly, most were not concerned about the issue of payment for the time they might spend on the project.

Making personal visits to the pharmacy to go through the process step by step with a number of key people in the pharmacy, with frequent contact during the pilot.

Pharmacists found that giving a copy of the information pages to the staff was helpful because everyone was familiar with what was happening in the study

Discussing the benefits of the study, not just the outcomes for their own pharmacy in reflecting on their current practice but also the potential benefits in preparing their practice for the arrival of the new wound care products that will be scheduled medicines. In short, the study could help the pharmacy be proactive rather than reactive in getting their wound care service up to scratch prior to the launch of the new products. This was a real incentive for pharmacists as they already felt a bit behind the 8 ball with regard to new drugs and saw this as a way to prepare for new products in their pharmacies.

9.9.1 CRITICAL SUCCESS FACTORS FOR RESEARCH IN COMMUNITY PHARMACY

This project identified a number of critical success factors for the project. These factors are similar to those identified in another wound care practice improvement project (Dorman, Moffatt et al. 1995), and relate to facilitating change. In this implementation of a community leg ulcer clinic, important success factors were acceptance of the need to change, communication,

133

staff training, ownership through the development of research-based treatment guidelines and identifying and using champions. Success factors for involvement in this research project were: Having an external mentor to work with the pharmacies to conduct research and a champion

within the pharmacy to keep the project on track and motivate other staff. The mentoring should involved face-to-face discussions with all staff to generate a

groundswell of interest. A champion for the project within the pharmacy, who is not necessarily the proprietor. There needs to be something to precipitate staff interest in the topic such as the owner’s

guidance, interest or commitment, lectures or education on the topic just prior to starting the project or that the research is in an area previously identified by the pharmacy as an area to focus on in the future.

There needs to be repeated communication between the mentor and the project champion often with repeated face-to-face meetings or site visits.

It is also important to link the research to an issue that staff or the pharmacy think is important.

Involving both the pharmacists and the pharmacy assistants in the project In this project, the pharmacist saw the involvement of pharmacy assistants as easing of the pharmacist’s load in the research and the assistants were excited at the possibility of participating thereby giving them extra recognition in the pharmacy. The researchers spent time and effort in designing the data collection tools and methods of data collection which bore fruit with the pharmacy assistants. They were expecting things to be complex or difficult to understand (due to their own lack of understanding about the nature and types of research that are done) and were relieved to see that the processes of data collection and recruitment were not complex, nor was the documentation too demanding or challenging. While pharmacy staff enthusiasm was a driver for the completion of the customer log, this empowerment did not extend to customer recruitment. Other barriers existed here.

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10. CONCLUSIONS AND RECOMMENDATIONS This research has allowed comparisons to be made between sites for benchmarking purposes as well as producing data on factors which influence outcomes that may be considered as part of the Continuous Quality Improvement cycle. There is potential to improve both patient and practice outcomes as well as optimise the wound care area as a core business activity with the potential for fostering growth in the area. This study contains a lot of data but 4 aspects stand out:

1. Quality in the provision of wound care services seems to be related to one underlying factor, the commitment of the proprietor or manager to wound care which leads to a decision to add value in this area. It might be argued that the term ‘wound care service’ ought to be restricted to those sites in which there is a conscious decision to value-add in this area. Currently wound care in many pharmacies is the passive supply of passive dressings instead of active selling of active dressings. Pharmacies need to sell products to meet needs, built on a commitment to problem solving.

2. Pharmacy assistants are critical in the provision of a quality wound care service. Strategies to improve the service must therefore be team based, including both pharmacists and assistants in the process.

3. In addition to the benchmarking details provided, the study highlighted that proprietor/manager impressions about the wound care service provided poorly reflect the actual situation as shown, for example, by the customer log. For pharmacies to carry out effective audits in any practice area, objective data must be compiled. Community pharmacies need to overcome reluctance to collect and assess this data for practice improvement purposes. This practice improvement data is a form of management information that many pharmacies do not use (the poor functionality of POS data in this study is an illustration).

4. The facilitation of research in community pharmacies is resource intensive and should include both the proprietor and staff, in particular, pharmacy assistants. Mentoring is required to guide staff and give them confidence to collect good quality data. Sites in this study had a lot of contact, often face-to-face, with members of the research team. This contact and support was felt to be a critical success factor for the completion of the pilot study.

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RECOMMENDATIONS Given that future wound care products are likely to emphasize the presence of active medicinal substances, pharmacy has an opportunity to become a dominant supplier in this niche market, the following recommendations relate to improving current services and building capacity to fill a wound care niche.

1. Education of pharmacists and pharmacy assistants in wound care practice must be a priority if community pharmacy wishes to remain as a credible service provider of wound care advice and products. This education should be at a level and delivered in a way that is relevant to practice.

With wound care products likely to reach the market in the next 5-10 years being more drug-related, pharmacies need to build capacity now especially in terms of staff training, knowledge and confidence. Interaction with more confident staff offering a more proactive wound care service will help change customer perceptions about community pharmacy as a wound care provider.

2. Benchmarking indicators for outcomes of community pharmacy wound care practices should be integrated into pharmacy IT systems as part of an ongoing quality assurance process and to provide evidence on which to base future government negotiations.

The quality measures and associated indicators collected in this study represents a preliminary dataset. To make the benchmarks more robust, more cases where the site is assessed against the quality measures would be required. Practice improvement also needs some goal posts - standards for the different levels of service should be developed. These standards need to show both a minimum standard, below which there is the potential to do harm, and a best practice standard, at which there is the potential to make an impact on wound outcome. The expert panel of this study has expressed interest in taking part in a project to establish these standards.

Pharmacists wishing to improve their wound care service quality (and indeed quality in any category), should collect objective information about their practices, for example, by keeping a record of staff training or a customer log to capture information on the type of wound presenting and the type of products sold or by using POS as a reliable source of management information. For the latter to be effective, pharmacies need to set up appropriate product sub-categories. It would be helpful if there was an Australian standard classification for the various dressing sub-categories.

POS/dispensing software companies could develop a module to enable wound care documentation and outcome capture. Such functionality could be incorporated into software to record pharmacy interventions. A working party should be established to determine suitable and standardised outcome categories. A similar process was used in the development of the Home Medicines Review documentation.

3. Benchmarking indicator methodology developed here should be translated into other areas of professional community pharmacy practice.

The choice of target is important to the success of the program – relevance to day-to-day practice is important.

4. Non-company based simple tools should be provided to community pharmacies to assist in wound care product selection.

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5. Protocols and resource booklets need to be developed to enable community pharmacies to better refer and network with local healthcare providers.

Community pharmacy needs wound care service tools that suit their needs and that can be incorporated into existing practice after which, pharmacy assistants may have more confidence in handling more complicated aspects of a wound care service. One such tool would also be beneficial to customers, namely, a simple tool to aid self-selection of more appropriate products. This tool would need to recognise the limitations of wound care skill and knowledge found at most community pharmacies while protecting customers from selecting a potentially harmful dressing by having triggers for consultation with the pharmacist or referral to other health professionals. Another tool wound be a resource booklet for wound care referral that indicated the locations and referral requirements for each wound care service provider. These tools will benefit from input from consumers and pharmacy assistants. Procedures for pharmacy assistants, modeled on the S2/S3 protocols should be developed to support the product selection guide and to reinforce the consultation referral triggers. The pharmacy organisations (e.g. PSA, PGA, QCPP) should sponsor the development of a proforma set of documentation tools, policies and procedures is a similar way to the kits provided as part of QCPP.

6. There is a need to better support rural community pharmacies in enhancing their wound care service.

A suite of interventions to support rural community pharmacies in enhancing their wound care service should be developed. The intervention needs to be multilayered with the inclusion of appropriate education strategies, procedures and tools and aids to help pharmacy staff better guide customers in product selection (which would require a level of wound assessment) and use. These interventions could be tested first in a study in the rural sector before latter more wide-spread implementation. In this study, a better way to operationalise customer feedback about the wound care service and wound healing (outcomes) could be explored.

7. Manufacturers need to pack dressings in sizes more suitable for sale in community pharmacy (e.g. pharmacy packs with 1-3 units/pack).

Community pharmacies would also benefit from having a niche wholesaler from which to purchase specialty wound products that are not stocked by larger, general pharmaceutical wholesalers

8. Self-selection by the customer would be facilitated by having basic written instructions for use of more advanced dressings available in the wound care section and by displaying simple visual aids to help customers select the best product or give non-brand specific choices for treatment.

Pharmacies need to give more support for customer self-selection of wound care since this practice is common and aiding self-selection is not considered as part of the quality domain by proprietors (Table 8.5). Information materials should be displayed such as the product selection tools described above that includes triggers to consult staff or for referral, and leaflets on use of specific products, a wound care “CMI”, could be developed, since adding instructions to the packaging of individual dressings is not feasible. Pharmacy assistant protocols should include the distribution of these leaflets to customers.

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9. There is an opportunity to develop wound care as a specialty practice by:

A focus on service delivery (stock range and staff knowledge better addressed) including staff interventions e.g. assistance selection and best use of dressings, customer follow-up of wound healing.

Appropriate merchandising for self-selection (since customers will still self-select, especially if the pharmacy is busy).

Focusing on wound care can be financially worthwhile for individual pharmacies, since the average gross profit margins for this category in a sample of 21 pharmacies was 38% compared to 29-30% commonly seen for the dispensary (data provided by Johnston Rorke Pharmacy Services).

10. Benchmarking indicators could be used to inform future Guild-government agreements so that these organisations could coordinate the collection and analysis of indicators longitudinally.

11. The critical success factors for research in community pharmacy should be recognised and supported by pharmacy organisations. Research projects conducted in community pharmacies should address the critical success factors such as mentoring and this should be allowed and expected as part of the costing of these projects.

A program of achievable, practice improvement projects in areas of interest to community pharmacies, such as the current study, could be run so that pharmacies can experience research in a less confronting way and appreciate the benefits of research, and so build research capacity.

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11. REFERENCES Audit Commission (UK) (2000) On Target - The Practice of Performance Indicators., The

Audit Commission (UK), London. Bankert, K., Daughtridge, S., Meehan, M. and Colburn, L. (1996) Adv Wound Care, 9, 21-29. Bolton, L. L., Van Rijswijk, L. and Shaffer, F. A. (1996) Nursing Management, 27, 30, 32-3,

37. Bowling, A. (1997) Research methods in health: Investigating health and health services.,

Open University Press, Buckingham, UK. Capasso, V. A. and Munro, B. H. (2003) AORN J, 77, 984-92, 995-7, 1000-4. Crealey, G. E., McElnay, J. C., Maguire, T. A. and O' Neill, C. (1998) Pharmacoecon, 14,

323-333. Dickson, S. (1997) Pharm Rev, 21, 44-45. Donabedian, A. (1980) The definition of quality and approaches to its assessment., Health

Administration Press, Ann Arbor, Michigan. Dorman, M. C., Moffatt, C. J. and Franks, P. J. (1995) Ostomy Wound Manage, 41, 34-42. Elliott, R. A., Woodward, M. C. and Oborne, C. A. (2001) Aust J Hosp Pharm, 31, 19-25. Fife, D., Barancik, J. I. and Chatterjee, B. F. (1984) Am J Public Health, 74, 473-8. Gasbarro, R. (1998) Pharm Times, 64, 74-76, 78-79. Gillies, A. (1997) Improving the quality of patient care., John Wiley & Sons, Chichester. Harding, K., Cutting, K. and Price, P. (2000) Br J Nurs, 9, S6, S8, S10 passim. Hayward, P. G. and Morrison, W. A. (1996) Aust Prescr, 19, 11-13. Hermans, M. H. and Bolton, L. L. (1996) Dermatol Nurs, 8, 93-4, 97-100. Holdford, D. and Schulz, R. (1999) Pharm Res, 16, 1344-1351. Holloway, S. (1999) Chem Drug, 251, 20-22. Kerstein, M. D. (2003) Dermatol Nurs, 15, 59-61. Kerstein, M. D. and Gahtan, V. (2000) Ostomy Wound Manage, 46, 22-6, 28-9. Marston, W. A., Carlin, R. E., Passman, M. A., Farber, M. A. and Keagy, B. A. (1999) J Vasc

Surg, 30, 491-8. McLaws, M. L., Gold, J., King, K., Irwig, L. M. and Berry, G. (1988) Med J Aust, 149, 582-

90. Mearns, M. (2003) Datacol Research, Pty. Ltd., Canberra, pp. 3. Meaume, S. and Gemmen, E. (2002) J Wound Care, 11, 219-24. Miller, M. (1996) Community Nurse, 2, 41-2, 44, 47. Morgan, D. A. (1990) Pharm J, 244, 295-297. Murphy, J. E. (2000) Am J Health Syst Pharm, 57 Suppl 2, S28-31. Newton, H. (1999) Nurs Stand, 13, 51-2, 55-6. Ortiz, M., Ledin, D., Thomas, R., Morgan, G. and Morland, R. (1987) Aust J Pharm, 68, 207-

214. Ovington, L. G. (2001) Home Healthc Nurse, 19, 477-83. Papadopoulos, A. and Jukes, R. (1999) J Wound Care, 8, 467-9.

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Parker, D. L., Carl, W. R., French, L. R. and Martin, F. B. (1994) Am J Public Health, 84, 606-11.

Peard, M. (2003) Aust J Pharm, 84, 41-42. Pharmaceutical Society of Australia (2002) Guidelines for managing pharmacy systems for

quality and safety. November. Phillips, T. J. (1996) OstomyWound Management, 42, 56-9. Pieper, B., Templin, T. N., Dobal, M. and Jacox, A. (1999) Adv Wound Care, 12, 117-26. Price, P. (1999) J Wound Care, 8, 306-8. Quality Care Pharmacy Program (2003a), Accreditations. viewed 24.9.03

http://www.qcpp.com/accreditations_for_about_QCPP.htm. Quality Care Pharmacy Program.

Quality Care Pharmacy Program (2003b) In Achieving Quality Care in Community Pharmacy in Australia., pp. 2.

Sanghani, S. (2003) Pharm J, 270, 374-375. Sarina, T. (1999) Aust J Pharm, 80, 130-132. Shanon, A., Bashaw, B., Lewis, J. and Feldman, W. (1992) CMAJ, 146, 361-5. Shekelle, P., MacLean, C., Morton, S. and Wenger, N. (2001) Ann Intern Med, 135, 647-52. Sidani, S. and Braden, C. (1998) Evaluating nursing interventions. A theory-driven

approach., Sage Publications, Thousand Oaks, California. Sinclair, H. K., Silcock, J., Bond, C. M., Lennox, A. S. and Winfield, A. J. (1999) Int J

Pharm Pract, 7, 107-112. Small, V. (2000) Nurs Stand, 15, 41-4. Smith, M. D., McGhan, W. F. and Lauger, G. (1995) Am Pharm, NS35, 20-29, 32. Stokes, J. A. (2003) Introducing Clinical Pharmacy as a Quality Use of Medicines

Intervention in Residential Aged Care. PhD Thesis In Department of Medicine, University of Queensland, Brisbane, pp. 392.

Strawbridge, J. and Kirke, C. (2002) Ir Pharm J, 80, 306. Sussman, G. (1998) Pharm Rev, 22, 67. Thomas, S. (1995) J Wound Care, 4, 447-451. Williams, D. M., Newsom, J. F. and Brock, T. P. (2000) J Am Pharm Assn, 40, 366-370. Williams, J. M., Furbee, P. M., Prescott, J. E. and Paulson, D. J. (1995) Ann Emerg Med, 25,

686-91.

A - 1

APPENDIX A - MATERIALS FOR FIRST EXPERT PANEL MEETING AGENDA FOR WOUND CARE EXPERT PANEL MEETING, 17 APRIL 2002 2.00pm Welcome and introduction of participants

Overview of project Outline of tasks for the expert panel Overview of “quality” terminology and concepts including characteristics of indicators

2.30pm Defining the scope of the service for which indicators are to be developed ”What is the nature of a community pharmacy wound care service?” • What are the actual or expected outputs/effects from/of the service – what is the

desirable outcome of the service? • What are the inputs into the service? • What activities are or should be done? • What elements are critical to achieving the desirable outcome – what elements are

important to various stakeholders? 3.00pm Afternoon Tea 3.15pm Brainstorming of possible indicators.

Consider methods of data capture and possible levels for any related standard. What tools or instruments are required?

3.45pm Issues for the pilot study 4.00pm Close

MEETING MATERIALS

Project Title: Wound care benchmarking in community pharmacy –piloting a method of QA indicator development.

Aim: To develop a set of effective performance indicators for wound care service quality relevant to community pharmacy practice

Project objectives:

(1) Establish an “expert panel” of stakeholders in wound care services provided by community pharmacy

(2) Use panel to generate a wound care service quality indicator set feasible for community pharmacy practice

(3) Test practicality & effectiveness of draft indicators in a pilot cross-sectional study to differentiate between different levels of service quality & to identifying specific areas for improvement

(4) Finalise indicator set for later intervention studies

Expert Panel Activities:• The development of draft indicators and associated

practice standards • The interpretation and review of pilot study findings• The revision of tested indicators to produce a final set

for further use

Why does community pharmacy need to evaluate

quality in wound care services?• To deliver the best possible care• To demonstrate pharmacy value adds to care• To identify areas for service improvement

Underlying assumption of quality evaluation is that high quality service gives a high quality outcome

Aim of project is to develop tools/techniques by which community pharmacies can evaluate quality

A - 2

What type of quality evaluation is required?

What is to be evaluated?Patient quality, carer quality, professional quality, management quality, of inputs, process and outcome, one aspect/part of the service or the whole service?

Who makes the evaluation?external quality inspectors, providers as part of self-review, quasi-independent developmental staff, external consultants/academics

When? Routinely, special studies, in response to a crisis or complaint

For whom?Tax payers, patients, government, owners, managers, health personnel, science

How?

Use ready made standards & systems, deriving & using users’ & stakeholders’ criteria, deriving and using professionals’ & managers’ criteria, evaluators’ criteria

Design

Patients’ perceptions after the service, expectations compared to experience, trends over time, service quality comparisons

(Ovretveit 1998)

Effective indicators need to:

Address structure, process, impact & outcome of service

Be responsive to different levels of service quality

Be relevant to stakeholders

Be practical & easy to apply

o Not be overly time consuming & can get a result in a reasonable time frame

Use available or easily collected data

o Have reasonable data collection costs given expected value

Include objective criteria supported by evidence*

Be reliable, valid & generalisable to wider pharmacy population

Suggest actions for an improvement process“Indicators should relate to aspects of care that can be controlled by decision makers” (Giuffrida,Gravelle et al. 1999)

“To be useful, the outcomes upon which the indicators are based must link to structures and processes that can be altered by the providers of care” (Gillies 1997 p151)

Scope of the service

”What is the nature of a community pharmacy wound care service?”

• What type of wounds are seen in community pharmacies?

• What are the intended effects of the service – what are the goals of services provided by different pharmacies?

• What are the inputs into the service?

• What activities are or should be done?

Describe the service using a cause & effect diagram

Brainstorming of possible indicators

What structural aspects are required to deliver a quality service?What processes are required?What are the effects (outcome/impact) of a quality

service and how can they be measured?o Outcomes need to be linked to structure & processes

care providers can alterConsider

Methods of data capture (what tools or instruments are required?)Possible “acceptable” levels for related standardsNeed to prioritise indicators?“how many”, ”how often”, “for how long”

Information sought from stakeholders during brainstorming:

• Current pharmacy wound care practices & data availability

• Feasibility of applying draft indicators as part of pharmacy practice

• Quality issues of concern to, and methods to collect data from consumers & other health professionals

• Specific aspects of quality wound care (what indicates “quality-in-fact”?)

• Ways of assessing outcome eg. Improved wound healing

• Secondary sources of dressing use/sales data• Alternative strategies to facilitate data collection eg.

Point-of-sale or dispensing computer

A - 3

WORKING MATERIALS SENT TO THE EXPERT PANEL AFTER THE FIRST MEETING Attendees: Mark Anderson State Manager, Healthcare Division, Smith & Nephew,

representing MIAA (Medical Industry Association of Australia Wound Care group)

Matthew Cichero Podiatrist Dianne Cunningham Wound care Specialist Nurse, Bluecare, Mt Gravatt Monica Di Ianni Research Officer, Therapeutics Research Unit, University of

Queensland, Princess Alexandra Hospital Greg Duncan Co-investigator. Lecturer & wound care pharmacist, Dept of

Pharmacy Practice & Wound Education and Research Group, Monash University

Dr Harry Gibbs Associate Professor of Medicine & Director, Vascular Medicine Department Princess Alexandra Hospital

Kathy Kendall Consumer representative Pete Marcus Manager IT Programs, National Secretariat,

The Pharmacy Guild of Australia Bob McDowell Community pharmacist, Pharmacy Guild of Australia (Qld

Branch) representative Prof Michael Roberts Co-investigator. Director, Therapeutics Research Unit,

University of Queensland, Princess Alexandra Hospital Sue Scott Community & hospital pharmacist, Pharmaceutical Society of

Australia (Qld Branch) representative Barbara Sponza Consumer, Diabetes Australia (Queensland) Julie Stokes Chief investigator. Research Pharmacist, Therapeutics Research

Unit, University of Queensland, Princess Alexandra Hospital Geoff Sussman Wound care pharmacist, Director, Wound Education and

Research Group, Monash University Sandy Wainwright Pharmacy Assistant representative Dr Stephen Yelland General Practitioner, Gold Coast Apologies: Dr Sheree Cross and John Chapman (Co-investigators) Meeting started at 2.10pm and closed at approximately 5pm. Geoff Sussman tabled documents about the wound care functions provided by wound care services, which provided a focus for discussions about the nature of community pharmacy wound care services. The following materials were developed by Greg Duncan and me after the meeting and incorporate many of the issues raised at the meeting. Additional information received from Sandy Wainwright and Kathy Kendall has also been incorporated. ACTION: Please review these materials and forward any ideas you have about indicators to me, preferably by email ([email protected]), or by fax (07 3240 7700)

A - 4

1. Best Practice Community Pharmacy Flow Chart Start ⇒




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

Yes




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

Yes

A - 5

Refer topharm-acist



collected fo far


this wound


progress

Progressnot OK

No

Durationof wound

Origin ofwound

<=4wks

>4wks

Yes




planned


up required

Episodecomplete

No

Arrangefollowup

Yes


Other HealthProfs

involved?



history


No


until appointment

Yes

Yes


No


up required

Arrangefollowup

Yes

Transfer careto OHP

No


use

No


up required

Arrangefollowup

Transfer careto OHP

No



until appointment

Yes


Episodecomplete




Refer

Refer topharm-acist



collected fo far


this wound


progress

Progressnot OK

No

Durationof wound

Origin ofwound

<=4wks

>4wks

Yes




planned


up required

Episodecomplete

No

Arrangefollowup

Yes


Other HealthProfs

involved?



history


No


until appointment

Yes

Yes


No


up required

Arrangefollowup

Yes

Transfer careto OHP

No


use

No


up required

Refer topharm-acist



collected fo far


this wound


progress

Progressnot OK

No

Durationof wound

Origin ofwound

<=4wks

>4wks

Yes




planned


up required

Episodecomplete

No

Arrangefollowup

Yes


Other HealthProfs

involved?



history


No


until appointment

Yes

Yes


No


up required

Arrangefollowup

Yes

Transfer careto OHP

No


use

No


up required

Arrangefollowup

Transfer careto OHP

No



until appointment

Yes


Episodecomplete




Refer

A - 6

Progressnot OK



customer needs

New treatmentplan

Consultother Health

Profs?



original history

Appropriateproduct

use/followingplan?

Yes

No No

Yes

Yes

No

No


repa

retre

atm

ent

plan

Yes

Transfer careto OHP



until appointment

Refer



up required

Arrangefollowup

No


Episodecomplete

Yes

Progressnot OK



customer needs

New treatmentplan

Consultother Health

Profs?



original history

Appropriateproduct

use/followingplan?

Yes

No No

Yes

Yes

No

No


repa

retre

atm

ent

plan

Yes

Transfer careto OHP



until appointment

Refer



up required

Arrangefollowup

No


Episodecomplete

Yes

Key: A community pharmacy colleague (a PhD candidate researching in the skin area) reviewed this flow diagram and made a criticism, that a wound duration of 4 weeks or more before a pharmacy assistant refers a customer to the pharmacist is too long. He suggested that referral

Decision Start/end Action or process Connector

A - 7

to the pharmacist should be made if the wound had not shown signs of healing within 10 days (but that this depended on the type of wound and any other complications). The flow chart does not explicitly describe 2 other possible situations: • What should happen when a customer requests a specific product. This product may have

been recommended by another health professional. Is this just a special case for the pharmacy assistant to seek information and to confirm the product selected (or if product does not appear OK, to refer to the pharmacist), or should the issue be explicitly addressed in the flow diagram.

• What is the process, what should happen when the customer does not accept the recommended product for various reasons e.g. too expensive. How often does cost limit choice?

Please give me your views. 2. History taking for “diagnosis” The preliminary information sought by a pharmacy assistant as the first customer contact should include the information needed to make the decisions in the flow chart (eg. wound duration, how wound started). Other information could also enable the pharmacy assistant to provide a high quality service: • Is the product for then customer or another person? • Other potential complicating factors e.g. does person with the wound have diabetes or

vascular problems. • What is the CDE (colour, depth, exudate)? Does the wound smell? These items were provided by Sandy Wainwright in an example of a pharmacy assistant wound care protocol she prepared. Elements of history taking by the pharmacist (for a more complicated wound) to include: • Origin (how, where wound started) • Duration • Treatment so far (and how successful this has been) • Drug and relevant medical/surgical history as they relate to wound risk and poor wound

healing • Tests done and any results of the tests • Who else is involved in customer’s wound care • Wound symptoms and signs +/- Observation of wound • Social/environmental factors contributing to wound risk and poor wound healing • Customer’s understanding of the wound and wound care 3. Practice levels Based on a review of the flow diagram, it is likely that 2 models of practice would best describe community pharmacy wound care services – basic service and an advanced (or niche) service. The following service elements are common to both practice models. In an advanced service, these elements might be performed/provided at a more intensive level, with the addition of other possible service elements (eg. changing dressings).

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9. Stock/supply chain 10. Identify customer requiring wound care service (even if wound care is not the primary

reason for the pharmacy visit) 11. Information collection to guide product selection or determine the need for referral or

other services 12. Decide whether referral is required and make referral 13. Supply appropriate products and advice (on their use and wound healing/care/prevention

as appropriate) 14. Data capture and documentation of the service 15. Follow-up 16. Quality assurance processes (eg. conduct patient surveys, aggregate and analyse data

captured) The basic service elements could provide a framework for indicators. Please comment on the basic elements. The key areas for wound care identified by Kathy Kendall can be related to these service elements. Kathy’s key areas were: 1. Product presentation and availability

Related to the display of products in a way that customers can self-serve if they wish. 2. Customer information

The provision information and wallcharts etc to assist a customer to self-select the most appropriate wound care product and how best to use the products. Customers have the right to be involved in the decision making to treat a wound. Some customers prefer to help themselves, others seek advice. Both choices must be supported.

3. Advising on treatment Helping the customer select the right product(s). This area was described as “Customer Screening” by Kathy. In this area of service, a trained staff member would assist the customer to select the product that meets his/her needs within his/hr cost limit. Advising the customer on the best use of the product would be an extension of the customer screen concept

4. Trained staff 5. Liaising and referral

This area would require a pharmacy to develop contacts/networks and relationships in a community that would allow the pharmacy to make appropriate referrals and to seek information should this be required to provide the best wound care service for a customer.

4. Needs Analysis The following needs (to have or to do) are based on the 4 steps to wound healing (diagnosis, address aetiologic/contributing factors, local wound management, monitoring) and were generated from some of the ideas raised at the meeting and after preparing the fllowchart. Please review the completeness and appropriateness of these needs as these could form the basis for indicator development. Please note that there is some overlap in these brainstormed ideas. Diagnosis • Procedures for staff on wound care decision making (eg. wound care protocols) • Procedures/proforma for information collection by the pharmacist (eg. for wound cause,

social and environmental factors, risk factors) • Adequate wound care knowledge base

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• Staff and pharmacists with appropriate training in wound care • Any relevant tools, aids or wound care information resources • Documentation forms and procedures (& record keeping processes) • Procedures that deal with customer consent and privacy (of records kept) • Adequate communication skills and information gathering skills • Procedures to keep knowledge and materials up to date • Known referral network • Referral procedures • Referral form • Appropriate wound assessment processes (define wound cause and type) • Appropriate processes to define risk factors • Space/area to do consultation • Need wound observation procedures • Area to observe wounds if appropriate [and to dress wound if appropriate] (area to hand

washing facilities) Address aetiologic/contributing factors • Adequate wound care knowledge base • Pharmacists with appropriate training in wound care • Referral network for non-local pharmacy wound care requirements (eg. podiatry,

nutrition, GP, compression stockings etc) • Counselling materials for risk factor minimisation eg. smoking cessation, nutrition • Patient education materials on risk factor minimisation • Adequate /sufficient history (taken in the diagnosis step) • Referral forms and procedures • Documentation procedures to demonstrate that contributing factors have been addressed • Communication skills to negotiate a referral with the patient and to educate patient • Need appropriate devices/products in stock eg. nicotine patches, nutrition products • Need trained staff to use/fit products if support services like compression stockings

offered • Space for consultation +/- fitting of compression hose Provide local wound management • Product range available has to be adequate for the types of wound encountered in the

practice • Need mechanism to maintain an appropriate and up to date product range eg wound care

stock management procedures eg. reordering • Flexibility in product ranges/kits supplied/promoted by manufacturers (ie. What standard

ranges are offered) • Space to display products • Need products arranged to facilitate selection of best product(s) for customers who wish

to self-serve • Staff and pharmacists trained to an appropriate level to advise on product selection (based

on data collected in “diagnosis” phase) • Staff and pharmacists appropriately trained about the use of products provided (and ? full

range of products stocked) • Staff trained in the management of the wound prior to applying the dressing eg. cleansing • Need aids to self-service product selection and how to use products

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• Need information for patient education and patient support (eg. as a takeaway leaflet) – could be the same as above

• Communication skills to (1) advise self-serve customers (eg. to extract information from a self-serve customer to assess whether the dressing they have selected is appropriate or where the dressing they have selected is not the best one) (2) educate customers on the use of products

• Need to address analgesia in the treatment plan • Need area to apply dressings if done (and disposal facilities for used dressings) • Need procedures on applying dressings in the pharmacy • Need sign inviting wound care consultation near wound dressings • Need staff customer service policy/procedures for wounds • Involve patient in development of treatment plan including any requirement for follow-up • Capacity to change a treatment plan and inform patient of change Monitoring • Policies/procedures on when and how to monitor wound progress • Feedback mechanism to capture progress (if any) • Documentation to record progress (with subsequent analysis of data for all customers –

CQI activity) • Review progress against treatment goal • Procedures to adjust treatment to achieve treatment goal • Space to review treatment • Communicate need for monitoring to customer • Educate customer on self-monitoring (+/- reporting monitoring results back to pharmacy) • Policies/procedures & forms to facilitate the above • Referral mechanism and documentation if referral is required on occasions after first

wound care contact between pharmacy and consumer (ie. Initial treatment not giving optimal results and now needs referral eg. infected wound)

These needs appear to fall under 5 main categories of needs: People Eg. to whom to refer, training level of staff

Policies/Procedures Eg. referral procedures, pharmacy assistant procedures

Communication Eg. negotiating the need for a referral with the customer, information sharing with other health professionals

Plant/Equipment (Physical resources) Eg. adequate/appropriate space, range of products, product display, disposal

Documentation/Data capture Eg. referral form, data retention (eg. of details for followup) within the provisions of the Privacy Act

5. Indicator ideas to date

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The following are ideas about possible indicators. I have included some questions to consider. Some panel members may be able to answer some of these. Please send me your comments Sandy has suggested some areas for which indicators could be developed: • How well educated are Pharmacy staff on Wound Care (W/C) products? • Do staff have a clear understanding of which wounds need to be referred? • How often is the pharmacist involved in the sale of W/C products? • What is the level of customer compliance? (are some products to hard for consumers to

use? eg: elderly) • What are realistic / appropriate W/C products for the general needs of the public?. • What is the definition of acute and chronic wounds? • What is the % of acute and chronic wounds in Community Pharmacy? • How would you determine a short term dressing? • How would you determine any dressing? • Do Pharmacist have details of Blue Nursers or GP they would refer. Kathy’s notes included the following (paraphrased) ideas: • Pharmacy product displays could be compared against some standards about what

constitutes a useful and effective display (from both self-treating customer and pharmacy perspectives)

• Provision of customer wound care fact sheets or similar • Provision of written information or charts about assessing wound types, warning signs for

wounds (eg infection, necrosis) and dealing with contributing factors • Are records kept of any wound care referrals to other health professionals? • For what proportion of wound care encounters was the protocol of information seeking

and guided product selection followed? • Is there are least one staff member with training on duty at all times – the indicator could

relate to how many hours a week this is the case • How successful has the pharmacy been at developing continuing relationships between

the doctors and hospitals in the area or how often clients come to the pharmacy with written communications to the pharmacy from doctors/hospitals with whom relationships have been established

Ideas for possible indicators from the meeting: • Does dressing range kept or sold match wound presentation pattern – pilot pharmacies

would have to prospectively record descriptions of wounds for people requesting dressings for a set period or until, say 30 episodes occurred. An audit of dressings kept and sold could then be taken and compared (using guidelines in RPBS book http://www1.health.gov.au/pbs/contents/sec1.htm).

• Timely supply of products – can information on the number of urgent orders or how many times an appropriate dressing for a wound was out of stock be collected? Perhaps collected by codes via POS? or on an electronic ordering system? Or from wholesalers?

• Level of knowledge about wound care and product selection and use – pharmacist and pharmacy assistants need to be tested to confirm that knowledge level supports their respective roles. A possible mechanism would be a quiz which addressed the basic and advanced levels of wound care service. Questions based on problems/scenarios would be less threatening. Perhaps the questions could also relate to some of the information seeking steps in the provision of wound care services. The quiz needs to point the way to

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how people can improve. Two separate quizzes of roughly equivalent level would be needed to test before and after any improvement activity. In the pilot, the research team would mark the quizzes but if implemented, the quizzes would be an in-house/self audit tool.

• Has appropriate referral been made? For referrals from the pharmacy to other health professional, this could have structure indicators that relate to whether of not a referral network has been established. It could also be tested using scenarios of different wound stories where the preferred action is referral to a range of different experts (eg. One case should be a foot wound that lead to referral to a diabetic clinic or podiatrist) – the pharmacies could be asked to name the specific people/places to which they wound refer such a patient in their own area. Perhaps the size of the network could be an indicator. As part if the referral issue, that pharmacist needs to be aware of entry requirements for particular services eg. No GP referral required for podiatrist but might need GP referral to community nursing service or diabetic clinic. The number of enhanced primary care referrals (formal) from GPs or referrals from other health professionals (formal referrals could be defined as written referrals) to the pharmacy for wound care services could be expressed as a proportion of transactions to purchase wound care.

• What proportion of referrals were structured referrals (define structured referrals). Would need mechanism to capture nominator (perhaps keep a copy of referral details but NB privacy act) and denominator (perhaps Point of sale (POS))

• What percentage of transactions have a diagnosis made? How would data to support this idea be collected?

• Does the pharmacy use recognised wound classification models? How to operationalise this concept?

• % of operating hours where staff trained in wound care on hand. The indicator should define what constitutes “trained staff”. [Question to test with pilot data: Should this include total trained staff hours/operation hours/week (eg. Where a pharmacy which opened 40hrs/week had one fulltime (40hrs) wound care trained assistant and another part-time (20hrs), the ratio would be 150%)?]

• % of pharmacists or staff reaching a certain skill level in wound assessment • Could a point-of-sale terminal be used to record that a wound care consultation or a

referral was made even if a transaction did not result. Events where a specific product or treatment plan was suggested but the customer chose a different treatment eg. Gauze and bandage, for cost reasons need to be recorded. In a review of sales, such transactions might be considered negative whereas all other aspects of the event might have been of high quality. Can such events be captured using POS or similar?

• Level of staff skill at fitting compression stockings if this is part of a pharmacy’s wound care service. How to measure??

• For first presentation of chronic wounds, % referred to GP for assessment. How could the denominators “first presentation chronic wound” be captured? Point of sale (POS) or similar would need to be used to capture the referral event.

• Another indicator suggested here, “% of chronic wound already treated currently by other health professionals” is, to a large extent, outside the control of the pharmacy and so could not be modified in any improvement strategy. Again, would need a mechanism to capture the denominator

• % of patients who adhere to local treatment plan – how to operationalise this? Is denominator all people who purchase a wound care product or all people followed up etc?

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• Have reasons for nonadherence been ascertained (eg, cost, ignorance, assistance required)? – a structural/process indicator for this might simply be that the pharmacy has a followup mechanism. Or that consent is sought from a prospective sample of patients to telephone them and followup wound adherence and progress etc.

A pharmacy could conduct a prospective patient survey for a window of time. All patients who purchase wound products could be asked if they would consent to a telephone call to see how they are going (use structured interview questions – what method of wound healing ? Gilman’s method). In the pilot, patients would have to consent perhaps to followup by the research team but in implementation, by the pharmacy. If a consent card was retained for each patient approached (indicating agreement or not), the completeness of the “consecutive” sample could be validated by comparing the number of patients approached against the number of wound care transactions. Need a hierarchical structure for indicators to reflect different levels of service. Initially, indicators could focus on the lowest common (acceptable level) denominator. A core set of between 6 and 10 should be the final set [note that more than 10 indicators might be pilotted to determine those that are effective, efficient and not too onerous to apply or too costly to collect data]. Outcome indicators need to be appropriate surrogates for wound healing. Ideas from subsequent discussions: The following ideas have arisen during discussions with my colleagues. • A means of cross-validating the level of wound care service is required. Sheree Cross

suggested that a ‘mystery shopper’ could visit pilot sites to test the quality of the service. It might be possible that the mystery shopper could be a person with an actual wound. The logistics of this approach would need to be addressed.

• Dressing use might be a proxy for wound healing rates (how many items were

purchased/episode) or appropriate use of dressings (eg. is repeat supply too early?) but to collect information on dressing use over the course of a wound healing episode, it would be necessary to store data linked to a specific patient. However, it is likely that POS systems do not link wound care product purchases to a specific patient unless the patient also fills a prescription or if the patient is a veteran getting a dressing under the RPBS, or, I presume, if the customer runs an account [Pete, how do I find out if this is true?]. There are 2 possible ways of dealing with this issue:

1. Use a sample of veterans. While use of dressings by veterans may be non-

representative, quality of wound care service for veterans may parallel quality for a wider population. Veteran related indicators could be: • Level of staff and pharmacist knowledge about the specialist wound care

dressings on the RPBS eg. alginates • What proportion of RPBS dressing categories are stocked. This could be adjusted

for the number of regular veteran customers attending the pharmacy in a given period (eg. >2 visits or prescription filling occasions over 6 months).

• Do the stock levels of RPBS dressings reflect wound commonly experienced by veterans, again adjusted for customer base

2. Give patients a card as a “patient-held record”. All items purchased could be entered

on to this card for each episode of wound healing, with the card being handed in at

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the end. Patients could also record other wound healing information. The draw back with this idea is that this data collection method is, in itself, an intervention. That is, it changes usual practice possibly for a longer period of time than conducting a telephone followup survey. This study is about giving pharmacists the tools to measure quality so that pharmacists can then change their practices as they see fit. The study is not about intervening to change practice. This may be a difficult balance to achieve.

Note that dressing provision to residential care made need it’s own set of indicators. The panel need to consider whether this aspect of dressing provision needs to be exclude for some or all of any indicators. Apparently, some facilities purchase dressings directly from suppliers, so that some aspects of wound care services may not be linked to supply. What do panel members think? 6. Additional Requested Actions: • Geoff Sussman has been asked to draft a quiz for pharmacy assistants to test knowledge

and training. Should a similar quiz be developed for pharmacists? • Information about the nature of wounds for which veterans are commonly treated should

be sought (?from DVA) to determine whether veteran dressing supply is indicative of any other aspects of wound care service (Julie).

• Mark Anderson was investigating the feasibility of using manufacturer’s data as a second form of validation for the quality of wound care services provided by pilot site pharmacies.

• Need to find out how each of the commonly used POS system etc will allow “intervention” or other data to be recorded with certain codes (eg. Minfos has a ‘club’ feature where certain bar codes could be entered to indicate and intervention eg. that advice was provided on product selection or that the customer reported improvement). This would also allow the types of wound presenting to be captured readily. Pete Marcus, would you please advise on this aspect?

B - 1

APPENDIX B – STUDY MATERIALS (PROCEDURES, CONSENT AND DATA COLLECTION FORMS) The following forms are included in this section Covering letter to the pharmacy together with the information sheet and consent form Instructions for the pharmacy about collecting data, using the forms and how the pilot will

be run The forms to be completed by the pharmacist and/or pharmacy staff:

o The customer log o The wound care service profile o Current wound care stock holdings and Wound care sales or purchase history o Pharmacist and pharmacy assistant quizzes

Customer survey information sheet and consent form. Two disposable paper rulers were attached to each information sheet

The customer survey telephone interview procedure and question sheet (survey conducted by research assistants)

The mystery shopper procedure and data collection sheet completed by research assistants (the shoppers)

An audit visit recording sheet, completed by an independent, trained observer (the same observer for all pharmacies)

THERAPEUTICS RESEARCH GROUP DEPARTMENT OF MEDICINE HEAD: PROFESSOR MICHAEL ROBERTS Princess Alexandra Hospital

Ipswich Road Woolloongabba Qld 4102 Australia Telephone (07) 3240 5803 International +61 7 3240 5803 Facsimile (07) 3240 5806

SCHOOL OF MEDICINE

18 March, 2003

Dear Re: “Quality of Wound Care Services in Community Pharmacy” pilot study Welcome to the pilot study to test measures of wound care service quality in community pharmacy. Enclosed is a kit containing most of the forms you will need to collect data for the trial:

• The “Customer Log” • The “Pilot Pharmacy Wound Care Service Profile” form • The “Current Wound Care Stock Holdings” form • The “Wound Care Sales or Purchases History” • Customer information and Consent forms x 15

The most important enclosed document is entitled “Important Instructions” – it should be read by both pharmacists and pharmacy assistants. Pharmacy assistants, in particular, should read the sections on “How to complete the Customer Log” and “How to recruit customers for a telephone survey”. Other sections may also be relevant to pharmacy assistants. The “Important Instructions” document covers all aspects of the trial including the definitions used in the trial, how to collect the information on the various forms, what is required to recruit and obtain informed consent from customers for a survey and what to do at the end of the trial (including how to invoice the study for payment). A flow diagram on page 6 of the instruction document shows all the steps of the trial. We will be sending the quizzes and the end-of-trial information request at a later time. If you have any questions, please contact me (email: [email protected], telephone 07 3240 5300, fax 07 3240 5806) or Greg Duncan (email [email protected], telephone 03 9903 9687, fax 03 9903 9629) Yours sincerely,

Julie Stokes, B.Pharm GDBus(InfoSys) PGDip Clin Hosp Pharm, PhD Principle Investigator

Wound care in community pharmacy version 2.1 1

Information for Pharmacies about participation in the “Quality of Wound Care Services in Community Pharmacy” pilot study About the study: The full title of the study is “Wound care benchmarking in community pharmacy –piloting a method of QA indicator development”. The aim of the study is to develop tools to measure the quality of wound care services provided by community pharmacies. Quality cannot be improved unless it can be ‘measured’. For individual community pharmacies, such tools could help continuous quality improvement (CQI) by highlighting specific areas for improvement or for benchmarking against wound care practice leaders. Study methods: The overall study has 2 phases. In the completed Phase 1, a multidisciplinary expert panel identified a range of possible ways to measure service quality. These possible measures will be tested in Phase 2, an 8 week pilot study. The pilot will include pharmacies with many different types of services, both small and large. The pilot study will examine whether the possible quality measures relate to pharmacy self-assessed wound care service quality and an independent assessment of service quality (using disguised shopper visits and observation by research staff). We expect that a final list of useful quality measures will come from the larger set of possible measures collected in the pilot. What we are asking you to do: If you consent to participate in the pilot and your pharmacy is selected, we will ask you to complete a “Wound Care Service Profile” and scenario based wound care quizzes (one for pharmacists and one for pharmacy assistants). You will be asked to keep a log of the types of wounds dealt with by your pharmacy over a specified time period and to recruit and seek consent from 15 consecutive consumers of wound care services (or as many wound care customers seen at the pharmacy in 8 weeks) for a customer survey. The survey will be carried out by the researchers but you will receive the summarised results. As part of the Wound Care Service Profile, information on current stock holdings of wound care products and purchases or sales of various dressing categories as a proportion of total wound care sales will be required. This may involve generating reports from point-of-sale and dispensary data, or seeking wholesaler reports. At the end of the pilot, we will interview you and some of the staff about your experiences in the trial and the costs of, and time involved for indicator data collection. The wound care sales proportions for the pilot period and stock on hand will be requested to capture any changes over the course of the pilot. Information provided by the pharmacy will be confidential and stored securely according to good research practice. A time commitment of approximately 10 hours is estimated. A payment of $300 will be made to pharmacies to defray some of the costs associated with the study (by invoice to University of Queensland – you will be notified of payment procedures). Two potential benefits for pharmacies participating in the pilot study: (1) Summarised service quality information collected as part of the pilot will be reported back to the

pharmacies. Individual pharmacies will be able to compare their performance to other, de-identified participating pharmacies. It is expected that these results will highlight areas for wound care service improvement.

(2) If the pharmacy is QCPP accredited, participation in this study will earn CQI credit points. Ten hours of participation by community pharmacies will equate to one CQI credit point. The study itself is the first step in a CQI process and so may contribute to additional CQI points.

Funding & Ethical Approval: The study has been funded by the Commonwealth under the Pharmacy Guild of Australia’s Third Community Pharmacy Agreement Research and Development Grants (CPA R&D) Program. A team of researchers from the University of Queensland School of Medicine at Princess Alexandra Hospital, Department of Pharmacy Practice at Monash University and the Australian Institute of Pharmacy Management is conducting the study. The pilot study has received ethical approval from Princess Alexandra Hospital and University of Queensland Research Ethics Committees.

Wound care in community pharmacy version 2.1 2

Consent conditions: • I understand the purposes, methods and demands of the study, and agree to adhere to the study

protocol. • I will fully respect customer confidentiality with respect to my involvement in this trial and agree

to properly protect personal information by such security safeguards as it is reasonable in the circumstances to take against loss, unauthorised access, use, modification or disclosure, and against other misuse.

• I undertake to: • Complete the Wound Care Services Profile and the pharmacist quiz. • To ensure that other staff pharmacists and assistants complete the respective quiz

assessments. • To provide the stock level information at the start and at the end of the pilot study. • To provide retrospective (where possible for 4 quarters) information about the relative

purchases or sales information of categories of wound products and for the 10 weeks of the pilot study.

• Maintain a log of wounds presenting at the pharmacy for 2 weeks • Recruit and gain consent from 15* consecutive customers seeking wound care products for a

customer survey (*or as many wound care customers seen at the pharmacy in 8 weeks). • To provide requested details of consenting customers to the research team who will conduct a

telephone survey. • I understand that I may withdraw my consent to participate in the trial at any time, without any

consequences to me or my customers. • I agree to advise the researchers of the withdrawal of any consumer from the consumer survey in

a timely manner. • I consent to the publishing of the results of this study, provided my identity is not revealed. Contact details for researchers: Ms Julie Stokes Therapeutics Research Unit University of Queensland Princess Alexandra Hospital, Q 4102 Ph 07 3240 5300 (direct) or 3240 5803 (to leave a message) Fax 07 3240 5806 Email: [email protected] Greg Duncan Department of Pharmacy Practice Monash University Parkville VIC 3052 Ph 03 9903 9687 Fax 03 9903 9629 Email: [email protected]

Community pharmacy wound care service quality consent form

I have received and read the ‘Information for Pharmacies’ sheet about the “Quality of Wound Care Services in Community Pharmacy” pilot study’.

• I understand the purposes, methods and demands of the study, and agree to adhere to the study protocol.

• I will fully respect customer confidentiality with respect to my involvement in this trial and agree to properly protect personal information by such security safeguards as it is reasonable in the circumstances to take against loss, unauthorised access, use, modification or disclosure, and against other misuse.

• I undertake to: • Complete the Wound Care Services Profile and the pharmacist quiz. • To ensure that other staff pharmacists and assistants complete the respective quiz

assessments. • To provide the stock level information at the start and at the end of the pilot study. • To provide retrospective (where possible for 4 quarters) information about the relative

purchases or sales information of categories of wound products and for the 8 weeks of the pilot study.

• Maintain a log of wounds presenting at the pharmacy for 2 weeks • Recruit and gain consent from 15* consecutive customers seeking wound care products for a

customer survey. (*or as many wound care customers seen at the pharmacy in 8 weeks) • To provide requested details of consenting customers to the research team who will conduct a

telephone survey.

• I understand that I may withdraw my consent to participate in the trial at any time, without any consequences to me or my customers.

• I agree to advise the researchers of the withdrawal of any consumer from the consumer survey in a timely manner.

• I consent to the publishing of the results of this study, provided my identity is not revealed.

I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

First Name Surname Pharmacy Name

hereby voluntarily consent and offer to take part in the study. Signed: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _

Witness Name: _ _ _ _ _ _ _ _ _ _ _ _ _ Witness Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Please return the completed consent form by Fax to: (07) 3240 5806

or by post to Wound Care Project P.O. Box 6067 Buranda Qld 4012

1

IMPORTANT INSTRUCTIONS Or Definitions and frequently asked questions

The attached Flow Diagram (page 6) shows the sequence of the various study activities including the time line for the activities. What do we mean by wound care services? • Service provided to a customer seeking advice or products for the treatment of existing

wounds, including small wounds for which first aid is needed. The service may be provided to a customer on behalf of the person with the wound/s.

• Excludes the purchase of first aid kits and the “just-in-case’” products people might make just so they have dressings on hand in case a wound occurs in the future. BUT please note: these transactions should be recorded on the Customer Log

• Excludes services related to sports strapping What do we mean by “wound care products”? • We mean those products that more than just simple first aid products eg. BandAids and

Elastoplast. We consider BandAids and Elastoplast type products to be simple first aid. • The adhesive tapes or bandages used to secure any dressing are not “wound care

products” for the purposes of this study Completing the Pilot Pharmacy Wound Care Service Profile Ideally, this form should be completed by a pharmacist who is the proprietor/managing partner or manager of the store, as someone who will know about day-to-day aspects and more management-type aspects of the operation of the pharmacy. • BUT some parts of the profile could be delegated. The pharmacist will need to answer

Part B and may need to answer some questions in Part C The profile collects a broad range of information about the pharmacy, its current wound care services, stock ranges and available resources, and policies and procedures. As the proprietor or manager, most of the information requested will be in your head but you may need to look up some things such as staff with formal wound care training. Information about current stock holdings may require a quick count of particular types of stock on hand (this could be delegated to a pharmacy assistant) Information about wound care sales or purchases history may require you (or another person delegated by you) to go back over wound care product sales or purchases records. What information is needed for the “Current Wound Care Stock Holdings form” This form asks for general information about the types and levels of wound care and simple first aid product stock holdings for various categories of products. See the glossary for the various category definitions and list of products. What information is needed for the “Wound Care Sales or Purchases History” form We are interested in patterns of sales over time of the various categories of wound care products (see glossary). We would prefer sales information but we realise that this may not be feasible and so will use purchases information from your wholesaler as a proxy for sales if necessary. How to complete the “Customer Log” See the separate instruction sheet with examples on page 2 of this document

2

How to complete the Customer Log • This log will help us understand just what type of wounds pharmacy staff see in this pharmacy. This log can be completed by pharmacy

assistants or pharmacists. • Keep the log for 2 weeks – please write the survey start date on the first page. If more pages are required of the log, please take a copy of

the second page or contact us and we will send extra pages. • Make an entry for EVERY customer who seeks wound care or first aid products or advice. • Date column: Record the date and approximate time (AM or PM) of the encounter • Wound type column: Record what type of wound the customer asked for help for. Tick the box that best describes the wound type the

customer asked you about (tick more than one box if they asked you about more than one wound type). If none of the categories are suitable, please write down what other type of wound it was. If you do not know, just tick the “Don’t know” box

• Product/s provided column: Record what wound care or first aid products, if anything, the customer purchased • Advice given by staff column: For customers who do not have a specific product in mind, indicate whether you feel that your advice

influenced the customer choice. If the customer requested a specific product, indicate whether you feel that your advice led the customer to change their choice. Indicate whether you referred the customer to another wound care practitioner (eg. doctor, hospital, wound care clinic). If a pharmacy assistant served the customer, did the assistant ask the pharmacist for advice. If your advice was to “go to the doctor” because you did not feel the customer should treat the wound themselves, circle Y for “changed customer’s choice” and Y for “referred on”

Here is are 2 examples. Customer 1 – asks for BandAids, he is going bush walking and may get blisters. You tell him about other blister treatments but he insists on BandAids. Customer 2 - A customer has a 5cmx1cm burn from the iron on the underside of her forearm that is quite painful. She wants something to protect it while it heals. You check with the pharmacist who recommends advise Solugel Gel or Clearsite Gel & she chooses Solugel.

Log for customer presentations for wound care or first aid Survey Start Date: _ _ _ _ _ _

Please record every customer seeking either wound care/first aid products or advice for a 2 week period

Date (circle time)

Wound type Product/s provided (write down) Advice given by staff (circle) – U=Unsure NA=not applicable

12/3/03 AM PM

None (for future use) Cuts & grazes Burns Leg ulcers/pressure sore Stitches/surgical wound Don’t know Other:

BandAid Shapes Influenced customer choice? Y N U NA Changed customer’s choice? Y N U NA Referred on? Y N Pharmacist asked? Y N

13/3/03 AM PM


Solugel Influenced customer choice? Y N U NA Changed customer’s choice? Y N U NA Referred on? Y N Pharmacist asked? Y N

12/3/03

3

What are the definitions of the different wound types mentioned in the Wound Care Service Profile and the Customer Log?: • Cuts and grazes – minor wounds where the skin is broken, some bleeding may occur, may

form a scab, and heals in a short period of time (less than 3 weeks). For the Customer Log, if cuts or grazes are extensive, write “extensive cuts & grazes” in the “Other:… section of the wound type column

• Leg ulcers or pressure wound – wounds that heal very slowly or not at all – present more than 4 weeks

• Burns – acute wounds as a result of heat or chemical injury to the skin. May be minor and quite painful or major with no pain.

• Stitches/surgical wound – stitches to close a wound or wound made during a surgical procedure

How to recruit customers for a telephone survey Who to recruit: • Every customer who visits the pharmacy for wound care products or advice for the

treatment of an existing wound. Do not recruit customers buying products “just in case” or those purchasing wound care items for someone else

• Screening possible survey participants: 1. Is the request/purchase related to a wound that someone has right now? 2. Is the customer the person with the wound IF NO to either question, do NOT recruit this customer for the survey

• Continue to recruit customers until 15 customers have been recruited or until the 8 weeks of the study is up – whichever comes first.

Obtain informed consent: It is important that consumers who agree to participate are properly informed about what to expect • Explain the purpose of the study is to test various ways to measure the quality of wound

care services provided by community pharmacies and that the consumer view is one of the most important things to measure.

• Explain what would be required of the consumer who agrees to participate (point to the section on the “Information for Consumers” sheet.

• Tell the consumer they are being asked to consent to the pharmacy sending the consumer’s contact details to the research team who will carry out the survey

• Assure the consumer that: o all their details and any answers they provide to the researcher will be confidential o the pharmacy will not know what answers they give as part of the survey. o they can withdraw from the survey at any time

• If the customer agrees to participate, ask them to complete the consent form (ensuring that the signature is appropriately witnessed)

What to do with the paperwork: • Tear off the back page with the consent form (you will need to fax this to the researchers)

and give the customer survey the information sheet, the instructions on measuring a wound and two disposable rulers

• Advise the customer that a member of the research team will telephone them to conduct the survey.

• On the same day each customer is recruited, please fax the completed consent to the researchers at Monash (VCP) Department of Pharmacy Practice on 03 9903 9629. It is important that the customer telephone survey be conducted as soon as possible after customer recruitment.

4

Wound care quizzes for pharmacy assistants and the pharmacists A separate envelope containing wound care quizzes and return envelopes will be mailed to the pharmacy. The envelope will contain 2 types of quizzes, one for pharmacists and one for staff. Please distribute these to personnel who would have contact with customers seeking wound care. The quiz does not require staff to look anything up, just to imagine that they are dealing with a customer as they answer each question. The completed quizzes can either be returned in one batch or mailed individually directly to us if there are confidentiality concerns. Returning forms We request that you and the staff return the different forms as follows: • After the 2 week observation period for the “Customer Log” is finished, please return the

following forms in the reply paid envelope provided: • The completed “Customer Log” • the “Pilot Pharmacy Wound Care Service Profile” form • the “Current Wound Care Stock Holdings” form • the “Wound Care Sales or Purchases History”

If you do not have the reply paid envelope, our postal address is: Quality Medication Care P.O. Box 6067 Buranda Qld 4102

• Please return the pharmacist and pharmacy assistant quizzes as soon as possible, preferably within 1 week of receipt. The forms can be mailed in a batch or separately (individual staff members may wish to send their quiz form directly to us at the above address)

• Please fax customer survey consent forms to the study office the same day that the form is completed.

When is the end of the trial? The pilot phase is 8 weeks from when you receive the Wound Care Profile form. What happens at the end of the trial • The researchers will telephone you or send a questionnaire to ask you about your

experiences in the trial. For example, they will ask you about how long each step took, what information was the most difficult and the easiest to compile, and ask your for your feedback on what customers thought and how customer recruitment went.

• You will be asked to report what wound care items have been sold over the 8 weeks of the pilot trial and the number of transactions for wound care or first aid over the time taken to recruit customers for the survey

• You will be asked to send an invoice for $ 300 to the University of Queensland. Please note that the university’s specific invoice content requirements must be met in order for UQ to process the invoice.

• The researchers will compile the results and send you a report of your pharmacy’s results and summary information for all pharmacies in the trial so that you can see where your pharmacy sits in the range of participating pharmacies. It is likely that this report will arrive about 1 month after the end of the trial

How to invoice the study at the end of the trial – depends on GST registration If you are registered for GST Please submit a tax invoice that is addressed to The University of Queensland and contains the following information: • Your business name, your ABN number and your address • Details of the services you are invoicing for • The total amount of the invoice (specify whether this is GST inclusive or exclusive)

5

If you are not registered for GST Please submit an invoice (not tax invoice) that is addressed to The University of Queensland and contains the following information: • Your business name, your ABN number (if you have one) and your address • Details of the services you are invoicing for • The total amount of the invoice (you are not entitled to claim for GST)

Glossary of Wound Care Product Groups

Product group Brands in this group Films • Biofilm

• Cutifilm, Cutifilm Plus • Opsite, Opsite post-op, Opsite

flexifix

• Polyskin • Tegaderm, Tegaderm island

Foams • Allevyn • Allevyn adhesive • Cavi-care

• Hydrasorb • Lyofoam • Lyofoam extra

Hydrocolloids • Combiderm • Comfeel range • Contreet • Curaderm

• Duoderm range • Replicare Ultra • Tegasorb

Hydrogels • Bandaid Healing Gel • Clearsite • Curagel • Duodermgel • Intrasite • Intrasite conformable

• Nugel • Purilon Gel • Safgel • Secondskin • Solosite • Solugel

Polymer dressings • Biatain • Cutinova Hydro, Thin, Cavity &

foam

• Polymem • Tielle

Alginates • Algisite M • Algoderm • Kaltostat

• Sorbsan • Seasorb range • Tegagen

Hydrofibre dressings • Aquacel • Aquacel Ag Cadexomer iodine • Iodoflex • Iodosorb Zinc paste bandages • Flexidress

• Gelocast • Icthopaste • Steripaste

• Tenderwrap • Viscopate • Zinc band • ZipZoc

Antimicrobial Barrier dressings

• Acticoat

Passive dressings • Adaptic • Airstrip • Aquaphor • Bactigras • Combine • Cotton wool • Cutilin • Cutiplast • Exu-dry

• Gauze • Hansapor • Jelonet • Melolin • Primapore • Release • Telfa • Unitulle

Simple first aid products • Bandaid strips • Hansaplast strips

• Elastoplast • Nexcare strips

6

Flow diagram of actions asked of this Pharmacy for the Wound Care Pilot Study

Day 0

Day 1

Timeline

Day 14

Day 55

Day 17




Purchases History

Start Customer log

recording










Day 27

Our contact details again: Julie Stokes Therapeutics Research Unit University of Queensland Princess Alexandra Hospital, Q 4102 Ph 07 3240 5300 (direct) or 3240 5803 (to leave a message) Fax 07 3240 5806 Email: [email protected] Greg Duncan Department of Pharmacy Practice Monash University Parkville VIC 3052 Ph 03 9903 9687 Fax 03 9903 9629 Email: [email protected]

Wound care study (U of Q & Monash) Log for customer presentations for wound care or first aid

Log for customer presentations for wound care or first aid Survey Start Date: _ _ _ _ _ _ _

Please record every customer seeking either wound care/first aid products or advice for a 2 week period

Date (circle time) Wound type Product/s provided (write down) Advice given by staff (circle) Y=Yes N=No U=Unsure NA=not applicable

AM PM


Influenced customer choice? Y N U NA Changed customer’s choice? Y N U NA Referred on? Y N Pharmacist asked? Y N

AM PM



AM PM



AM PM



AM PM



AM PM



AM PM



AM PM



AM PM



WC Profile v1 1

Pilot Pharmacy Wound Care Service Profile ID No.: _ _ _ _

Purpose of Profile: This profile will allow the research team to develop a wound care service profile that could ultimately be used by individual pharmacies as a “diagnostic” tool for their wound care services. We appreciate that we are asking for sensitive commercial information but this is required to work out just what information will give really useful feedback on service quality. We undertake to keep your information secure and confidential. Once the final profile is developed, pharmacists who subsequently choose to complete the profile would keep this information themselves to monitor service quality in-house.

This profile asks for information that will be used to define and understand the quality of the wound care service provided by this pharmacy (such as structural, resource and demand for service aspects). As influences on customer demand for wound care services, information on the characteristics of a pharmacy and its location is requested.

Date form completed: _ _ _ _ _ _ _ _ _ Part A Pharmacy Characteristics and workload information 1. What are the opening hours for the pharmacy? (eg. M-F 8.30am to 6pm, Sat 9am-4pm)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. On average, how many prescriptions are dispensed per week by this pharmacy? (tick ONE box that best describes this pharmacy)

≤ 300 301-800 801-1200 1201-2000 2001-3000 > 3000

3. What are the effective full-time equivalent (EFT) staffing levels in this pharmacy: Pharmacists _ _ _ _ Pharmacy assistants (front-of-shop & dispensary) _ _ _ _

4. How many pharmacists who work in this pharmacy have been registered: Less than 5 years _ _ _ _ 5 or more years _ _ _ _

5. For how many hours a week is there more than one pharmacist on duty? _ _ _ _ _ _

6. Is this pharmacy QCPP accredited? (Circle yes or no) Yes No

If NO, how far has the pharmacy progressed towards accreditation? (tick ONE box)

None Some but less than 50% 50% or more

7. Does this pharmacy supply wound products to: (Circle yes or no)

(a) residential aged care facilities Yes No (b) community nursing organisations Yes No

Part B Proprietor/Manager perceptions of service and quality For Questions 1 to 4, place a cross on the line below each question to indicate your quality or service rating

1. Overall, what do you perceive is the level of quality of wound care service provided by this pharmacy?

Poor Excellent

2. What level of wound care service do you believe is provided by at this pharmacy?

Rudimentary Advanced Basic first aid only eg. treat complex chronic wounds

3. Do the space and facilities of this pharmacy meet the needs of the level of wound care service provided at this pharmacy?

Needs not Needs at all met completely met

WC Profile v1 2

4. How well organised is the wound care display area to help customers self select dressings? Does not Fully assists

assist self-selection self-selection

5. Can customers take any written material about wound care away with them? Yes No

If YES, please describe the source of information (eg. computer printout or manufacturer’s pamphlet)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

6. In the last 2 weeks, for any wound care transaction: (Circle yes or no) (a) Did a pharmacy assistants seek your input? Yes No (b) Did you take a detailed history of the wound? Yes No (c) Did you keep a written record of this consultation? Yes No (d) Was a customer persuaded to purchase a more appropriate Yes No dressing than the one they initially requested or selected

7. Of all the customers coming to this pharmacy for wound care, please estimate the percentage of customer with each of the following wound categories (only global impression required but please total to 100%): None (product for future use) _ _ _ _ % Cuts & grazes _ _ _ _ % Burns _ _ _ _ %

Leg ulcers _ _ _ _ % Pressure sores _ _ _ _ % Stitches/minor surgical wound _ _ _ _ %

Large surgical _ _ _ _ % Other _ _ _ _ % (please give examples of other wound types seen) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

8. Do you have the opportunity to see wound care customers more than once Yes No so that you can monitor their wound healing progress?

If YES, do you routinely monitor healing or review treatment in a given Yes No wound care episode for a customer?

9. In the last 4 weeks, approximately how many customers have you referred _ _ _ _ _ to other health professionals or services/clinics for wound care?

10. In the last 3 months, have any customers been referred to you by other Yes No health professionals for wound care services

Part C Stock and Sales

1. How do you select the range of products you stock eg. advised by banner group? Please list the factors you consider starting with the one that has the greatest influence on your decisions.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. Do you review the range of wound care products you stocked? Yes No

If YES, (a) Please describe how you conduct this review (eg. examine sales figure or after speaking with product

representatives)? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(b) In the 12 months, have any changes been made to the stock range carried? Yes No

WC Profile v1 3

3. In the last financial year, approximately what proportion of the pharmacy turnover was related to wound care products (including compression stockings)? (tick ONE box for this ESTIMATE )

less than 1% 1-2% 2-3% 3-4% 4-5% greater than 5%

4. In the last 2 weeks has the pharmacy: (Circle yes or no)

(a) been out of stock of a requested wound care item? Yes No (b) supplied a second choice wound care item (because the ideal product was not in stock) Yes No

What is the source of this information? eg. stock book or best guess _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Please complete the attached “Current Wound Care Stock Holdings” form OR attach another type of inventory report that provides the same type of information

Please complete the attached “Wound Care Sales or Purchases History” form OR attach another type of report that provides the same type of information

Part D Human and information resources 1. How many of your pharmacy assistants have received any wound care training? _ _ _ _ _

If any staff have wound care training,

(a) How many have received any training in the last 2 years? _ _ _ _ _ _

(b) In the last week, for what percentage of the pharmacy trading hours was a _ _ _ _ _ _% pharmacy assistant with wound care training on duty?

2. How many of the pharmacists in this pharmacy undertaken any professional _ _ _ _ _ _ development in the area of wound care in the last 2 years?

Please describe the activities. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. Does this pharmacy have any other, specialist staff (eg. nurse) providing wound care services? (Circle yes or no) Yes No

4. Do you know of other health care providers in your area that you can refer Yes No customers to when they require complex wound care? (eg. community nursing services, wound clinics, podiatrists, hospitals etc)

If YES, is this resource information documented? Yes No

5. Are there information resources in the pharmacy for staff to refer to for more information on: (a) wound assessment? Yes No (b) product selection and appropriate use? Yes No

6. If yes to either (a) or (b) above

(a) Please describe the information resources _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(b) How current is this information or when was it last updated? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

WC Profile v1 4

Part E Policies and procedures

1. Do you document any of the information you collect in your (Circle yes or no)

discussions with customers about wound care? Yes No

If YES, do you have a standard form to guide collection of relevant patient data? Yes No

If YES, please attach a copy of the form, guideline or policy.

2. Do you have any other documents or standard forms to support the wound care services provided by your pharmacy? (Please tick all that apply)

• wound care referral form (to other health care practitioners) • record of wound care treatment recommended or provided • records of wound monitoring and review of wound healing

3. If you keep patient wound care records, do you record the outcome of wound care?

(Circle yes or no or N/A) Yes No N/A – no wound care records kept

4. Please complete the following table to indicate whether or not this pharmacy has policies or procedures addressing the following aspects? A policy or procedure may be written or unwritten. If there is no policy or procedure, please indicate whether you believe it to relevant to this pharmacy.

Tick ONE box for EACH aspect Wound care practice aspects None - Not relevant here

None but relevant

Yes, unwritten

Yes, written

Maintaining appropriate levels of dressing products from relevant categories

For staff advising customers on appropriate use of all products stocked (covering aspects such as pre and post dressing activities such as wound cleansing, bathing, etc)

When and how to monitor wound progress Wound care training or education requirements • For pharmacy assistants

• For pharmacists Maintaining current wound care knowledge and skills • For pharmacy assistants

• For pharmacists Decision making for wound care addressing when to treat and when to refer

• For pharmacy assistants

• For pharmacists How to make a wound care referral to another practitioner Maintenance of wound care resources (counselling aids, sample and placebo products, patient education material, etc)

Part F Time taken to complete this form Approximately how long did it take to complete this profile form, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ EXCLUDING the time taken to provide the information requested on stock holdings and sales history

Pharmacy ID __ __

Current Wound Care Stock Holdings

Please attach an inventory of the current wound care stock on hand. Please indicate the brand name, number of different dressing sizes stocked and the numbers of single dressings on hand. *See glossary for definitions and examples

Product group* Which brands do you stock?

How many different sizes?

How many single dressings in this class do you have in total? (eg 2x boxes of 10 intrasite + 2 loose intrasite = 22 single dressings)

Films

Foams

Hydrocolloids

Hydrogels

Polymer dressings

Alginates


Cadexomer iodine

Pharmacy ID __ __

Product group* Which brands do you stock?

How many different sizes?

How many single dressings in this class do you have in total? (eg 2x boxes of 10 intrasite + 2 loose intrasite = 22 single dressings)

Zinc paste bandages

Passive dressings


Do you keep compression hosiery?

Yes No If yes, which brand(s)? Please list manufacturer How long did it take to compile this information (in minutes or hours) __ __ __ __ __

Pharmacy ID __ __

Wound Care Sales or Purchases History

The purpose of this document is to determine the trends over time in wound care product sales in this pharmacy. We are asking you for number of individual units rather than actual dollar value. If you cannot extract wound care sales data from your point of sale system you can use information on your purchases of wound care products from your wholesaler or other source for the same period as it is the proportions of various types of wound care products we are interested in rather than actual sales value.

For each of the last 4 quarters please provide the percentage of total wound care sales for each of product groups in the table below. See the glossary in the “Definitions and Frequently Asked Questions” document to determine the product group for each dressing product.

What type of data was used?

sales data (from POS) purchase data (from wholesaler)

Product group 1st Quarter

Jan-Mar 2002

2nd Quarter

Apr-Jun 2002

3rd Quarter

Jul-Sep 2002

4th Quarter

Oct-Dec 2002

Films

Foams

Hydrocolloids

Hydrogels

Polymer dressings

Alginates


Cadexomer iodine

Zinc paste bandages

Passive dressings


How long did it take to compile this information (in minutes or hours): _ _ _ _ _ _ _ _

Do not include time waiting for response from wholesaler, etc.

Pharmacist Quiz Pharmacy ID _ _ _ _ _

• This is a short questionnaire and quiz for pharmacists, both proprietor/managers and employee pharmacists.

• The quiz does not require you to look anything up

• Please complete and return the form as soon as possible. You can return the form to the research team together with other forms or by mailing it directly to the researchers. Our address is:

Quality Medication Care P.O. Box 6067, Buranda, Qld 4102

1. Please tick any of the following situations when you would expect a pharmacy assistant to automatically refer to the pharmacist or seek other help







2. Circle True or False for EACH of the following statements

Lyofoam is a foam dressing True False

Film dressings, eg Opsite or Tegaderm, are good for bleeding wounds True False

Duoderm can be used on any wound True False

A scab is good as it protects the wound True False

Moist wounds heal faster than dry ones True False

Applying local pressure can help stop minor bleeding True False

Dressings with charcoal in them are for smelly wounds True False

Dressings should always be changed at least once each day True False

You should never use Betadine on any wound True False

Hydrogels dressings (eg Intrasite or Solugel) are only good for wounds with True False a lot of fluid or exudate coming out of them

Solugel can be used on chicken pox and minor burns True False

Gauze is a good dressing to use on any wound True False

Please go to next page

Pharmacist Quiz Pharmacy ID _ _ _ _ _

3. Please give a short answer to the following questions (a single sentences should suffice).

i) A regular customer of your pharmacy is collecting his prescription for his gliclazide and asks for some Melolin® for a sore on his shin. On inquiry, he tells you that it has been there for about two weeks after he scratched it in the garden and doesn’t seem to be getting any better. It is still painful. He says it is about the size of a 10 cent piece and his dressing gets so wet he needs to change it at least twice a day. What would be the key factors you would consider that would indicate the need for you to refer him to his GP?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ii) Do sodium or calcium alginates act as a haemostatic agent? Please name one brand of this

type that acts as a haemostatic agent.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ iii) The vertical wicking properties of Aquacel mean what?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

iv) What makes a hydrogel a useful treatment for chickenpox?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

v) What feature of a wound would influence your choice of a foam dressing instead of a hydrocolloid?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

vi) What are the simple indications for using a zinc paste bandage?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4. Did you use any information resources to help you respond to Question 3? (Circle yes or no) Yes No

If YES, what resources did you use? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5. Approximately how long did it take you to complete this quiz? _ _ _ _ _ _ _ _ _ _ minutes

Pharmacy Assistant Quiz Pharmacy ID _ _ _ _

• This is a short questionnaire and quiz for pharmacy assistants. The quiz does not require you to look anything up – imagine you are dealing with a customer as you answer each question.

• Please complete and return the form as soon as possible. You can return the form 2 ways – either by giving it to the pharmacist to return to the research team together with other documents or by mailing it directly to the researchers. Our address is:

Quality Medication Care P.O. Box 6067, Buranda, Qld 4102

Quick Quiz

1. Please tick any of the following situations that would you automatically refer to the pharmacist or seek other help







2. Circle True or False for EACH of the following statements

Lyofoam is a foam dressing True False

Film dressings, eg Opsite or Tegaderm, are good for bleeding wounds True False

Duoderm can be used on any wound True False

A scab is good as it protects the wound True False

Moist wounds heal faster than dry ones True False

Applying local pressure can help stop minor bleeding True False

Dressings with charcoal in them are for smelly wounds True False

Dressings should always be changed at least once each day True False

You should never use Betadine on any wound True False

Hydrogels dressings (eg Intrasite or Solugel) are only good for wounds with True False a lot of fluid or exudate coming out of them

Solugel can be used on chicken pox and minor burns True False

Gauze is a good dressing to use on any wound True False

Please go to next page

Pharmacy Assistant Quiz Pharmacy ID _ _ _ _

Your views on wound care provided in this pharmacy

1. Of all the customers coming to this pharmacy for wound care, please estimate the percentage of customer with each of the following wound categories (only impression required but please total to 100%):

None (product for future use) _ _ _ _ % Cuts & grazes _ _ _ _ % Burns _ _ _ _ %

Leg ulcers _ _ _ _ % Pressure sores _ _ _ _ % Stitches/minor surgical wound _ _ _ _ %

Large surgical _ _ _ _ % Other _ _ _ _ % (please give examples of other wound types seen)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. In the last 2 weeks, approximately what percentage of wound care customers have been persuaded to purchase a more appropriate dressing than the one they _ _ _ _ _ % initially requested or selected?

Wound care training and knowledge 1. Have you received any wound care training? (Circle yes or no) Yes No

If YES, please describe the type of training and how approximately how long ago this took place.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Approximately how long did it take you to complete this quiz? _ _ _ _ _ _ _ _ _ _ minutes

Information for consumers about the “Quality of Wound Care Services in Community Pharmacy” pilot study

We invite you to take part in a survey of consumers who visited this pharmacy for wound care reasons. This survey is part of a study to develop tools to measure the quality of wound care services provided by community pharmacies. Consumers’ impressions of these services are a key area to measure. Your feedback will provide important information that may help pharmacies improve the service they provide to consumers in the future. What it will involve: • Answering some simple questions about your wound care experience at this pharmacy

when a researcher telephones you (approximately 10 minutes). The researcher may ask you to measure the size of the wound with the disposable paper ruler provided.

• Depending on your wound, you might receive a second call 2 weeks later to check on the size of the wound (using the second disposable paper ruler provided)

What you are being asked to consent to: The conditions written on the consent form you will be asked to sign are in the box below. Please take this information sheet with you for your reference.

I understand that: • I will be telephoned by a researcher who will ask me several questions about my wound

care experiences in the pharmacy and about healing of the wound/s. I may receive a second call from the researcher to ask about the progress of my wound healing.

• I therefore consent to this pharmacy providing the contact details on this form to the researchers for the purposes of the telephone interview.

• No identifying information relating to me will be disclosed by the researchers1 to any person, body or agency.

• My details and answers will be confidential and stored securely. • This pharmacy will not be able to identify the answers I give in the interview. Only

summary information from the consumer interviews will be available to the pharmacy. • I can decline to be interviewed at a later time. This will in no way affect the service I

receive from the pharmacy. I can withdraw by telephoning the researchers on: 03 9903 9687 or 07 3240 5803 or by advising the pharmacy who invited me to participate.

• The project may not be of direct benefit to me. I voluntarily consent and offer to take part in a survey of consumers who have received wound care services or wound products from this pharmacy. I consent to the publishing of results from this study provided my identity is not revealed. The details you are asked to provide are your name, how you would prefer to be addressed (e.g. Mr, Mrs), a contact telephone number, the best time to contact you and a postal address in case the researchers cannot reach you by phone. The pilot study has received ethical approval from Princess Alexandra Hospital Research Ethics Committee and the University of Queensland Medical Research Ethics Committee. 1. The researchers come from the University of Queensland School of Medicine at Princess Alexandra Hospital, the Department of Pharmacy Practice at Monash University and the Australian Institute of Pharmacy Management.

Information for consumers about the “Quality of Wound Care Services in Community Pharmacy” pilot study

Has your wound/s been present for 2 weeks or more? If so, we would like to assess wound healing by measuring the wound on 2 occasions How to measure your wound • Do not undo your wound dressing specially to measure your wound for this survey.

• Measure the size of the wound next time you undo or change the wound dressing.

• Take one of the paper rulers from the from of this form and use it to measure the size of the wound or the biggest wound if you have more than one wound currently being treated.

• Measure the longest part of the wound (top to bottom) and the widest part (sideways). If the wound does not have a regular shape, do your best to work out which is the upper most edge of the wound and which is the lowest edge. Please remember which part of the wound edges you measured between for this first measurement. Then you will be able to measure the wound from about the same place if we ask you to make a second measurement about 2 weeks later.

• Throw out the used paper ruler.

• Write down the measurement of your wound here:

First Wound Measurement: _ _ _ _ _ _ _ _ _ centimetres LONG

Date measured: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ centimetres WIDE

Please repeat the wound measurement after 2 weeks, using the second, unused paper ruler.

• Take the measurement when you are changing the dressing – do not undress the wound specially to measure it for this survey.

• Please repeat the measurement of the wound between the same edges of the wound you measured the first time. Then throw out the second paper ruler.

• Write down the measurement of your wound here:

Second Wound Measurement: _ _ _ _ _ _ _ _ _ centimetres LONG


Please keep this page so that you can easily pass this information onto the researcher when they telephone you. Thank you for your assistance.

Consent to provide consumer feedback about community pharmacy wound care services.

Pharmacy to fax consent form to: Greg Duncan at VCP Dept of Pharmacy Practice on 03 9903 9629

I have received and read the ‘Consumer Information Sheet’ about the “Quality of Wound Care Services in Community Pharmacy” pilot study and understand the general purposes, methods and requirements of the study. All of my questions have been answered to my satisfaction. I understand that: • I will be telephoned by a researcher who will ask me several questions about my wound

care experiences in the pharmacy and about healing of the wound/s. I may receive a second call from the researcher to ask about the progress of my wound healing.

• I therefore consent to this pharmacy providing the contact details on this form to the researchers for the purposes of the telephone interview.

• No identifying information relating to me will be disclosed by the researchers1 to any person, body or agency.

• My details and answers will be confidential and stored securely. • This pharmacy will not be able to identify the answers I give in the interview. Only

summary information from the consumer interviews will be available to the pharmacy. • I can decline to be interviewed at a later time. This will in no way affect the service I

receive from the pharmacy. I can withdraw by telephoning the researchers on: 03 9903 9687 or 07 3240 5803 or by advising the pharmacy who invited me to participate.

• The project may not be of direct benefit to me. I voluntarily consent and offer to take part in a survey of consumers who have received wound care services or wound products from this pharmacy. I consent to the publishing of results from this study provided my identity is not revealed. Consumer First name and Surname: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Please Print

Consumer Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ Witness Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Please Print Pharmacy Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Contact details for telephone interview:

How would you like the interviewer to address you (Circle)? Mr Mrs Ms Other title: _ _ _ _ _

What is your contact telephone number? _ _ _ _ _ _ _ _ _ _ _ _ _

What is the best time to reach you by telephone _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (time and day of the week)?

What is your postal address in case we cannot reach you by phone?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1. The researchers come from the University of Queensland School of Medicine at Princess Alexandra Hospital, the Department of Pharmacy Practice at Monash University and the Australian Institute of Pharmacy Management.

Consumer telephone survey for wound care study

Procedure for customer interview • First, read consumer consent/information sheets to understand the instructions given to customers. • As soon as possible after receipt of the customer consent form and in keeping with the times

specified by the customer, contact the customer and conduct the interview. • Introduce yourself (give name) as being from the Department of Pharmacy Practice at Monash

University. • Ask to speak with the customer named in the consent form • Indicate you are calling to conduct about a survey about wound care services from

_ _ _ _ _ _ _ _ _ _ _ _ Pharmacy that the customer agreed to participate in. [Confirm the respondent’s name and pharmacy providing the service with the respondent]

• Check for inclusion criteria, that the wound care service related to a wound or wounds that someone has now, and that the person with the wound is the person consenting to the survey

• If the customer does not recall the consent, try some reminders, and if necessary, go over the conditions of participation again (some questions about wound care services and perhaps, assessing how their wound is healing)

• Advise the consumer that the interview could take about 10 minutes and confirm their readiness to proceed.

• If the time is not suitable, arrange to call at a better time, and conduct the interview then. • Ask the consumer the questions and read out any associated categories (except for wound type). • Record responses as phrases and concepts, unless you are required to categorise responses as

they are given (eg. wound type). Note, record the wound description for later coding. Codes likely to be: Small to moderate sized cut, large cut, graze, sunburn, scald, other burn, splinter/puncture wound, leg ulcer, pressure wound, blister, diabetic foot wound, post-operative wound, surgical wound breakdown.] If the wound has been present for 2 weeks or more at first interview, the interviewer should ask the respondent “Next time you change the dressing, please measure in centimetres the longest and widest parts of the wound and write this down”. Remind the consumer about the “How to measure your wound” information sheet. Seek verbal permission from the respondent and arrange a time to contact them again in about 2 weeks when the interviewer will again ask about wound size at the last interview and wound size at the next interview. On the second call:

1. Ask the respondent to report the initial wound dimension and current dimension.


Date and time of 1st interview: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Interviewer: _ _ _ _ _ _ _ _ _ _ _ _ _ • Indicate you are calling to conduct about a survey about wound care services from

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Pharmacy that the customer agreed to participate in. • Confirm the respondent’s name and pharmacy providing the service with the respondent

• Confirm eligibility with inclusion criteria Eligible Not eligible 1. When you need something, not only wound care, from a pharmacy, how often do you use this

pharmacy? Almost always Two thirds of the time, About a third of the time Only very occasionally.

2. Can you briefly describe the nature of the wound for which you were seeking treatment when you

visited the pharmacy?

• What type of wound is it or what caused it? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

• Where on the body is the wound? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

• About how big is the wound? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Code later: 3. How long have you had this wound? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NOTE: if the wound has been present for 2 weeks or more – at the end of the interview, ask the consumer to measure the wound as per the “How to measure your wound” instructions

4. What wound care product/s did you get from the pharmacy for the wound?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. How did you choose those products?

Recommended by Doctor Recommended by Nurse, Pharmacy assistant recommended Pharmacist recommended. Recommended by other Health Prof _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Selected product his/herself Don’t know/not sure

• If you selected the products yourself, did you find that the way the display was arranged helped you make your choice? Yes Somewhat No

6. Of the pharmacy staff, who was involved with your wound care purchase? a. Was a pharmacy assistant involved? Yes No Not sure b. If yes, did they ask you anything about the wound? Yes No Not sure c. Was a pharmacist involved? Yes No Not sure d. If yes, did they ask you anything about the wound? Yes No Not sure

7. How do you use the dressing/s or how often do you change the dressing/s?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


8. Did the pharmacist or pharmacy assistant give you any information about (clarify whether or not any of this information was written): (1) using the dressing Yes, written Yes, spoken No (2) what to expect as the wound heals? Yes, written Yes, spoken No

9. When you were seeking wound care products, how would you rate the level of help you received from the staff? (read categories)

Excellent Very good Good Fair Poor

10. Has anyone else given you information about dressing your wound? Yes No

If Yes, Who: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

If Yes to Q8 and Q10, who gave the most useful advice?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

11. How would you rate the length of time you waited to get the wound care service you wanted? Excellent Very good Good Fair Poor

12. Overall, how did the pharmacy rate in meeting your wound care needs eg. product availability, advice and customer service?

Excellent Very good Good Fair Poor

13. Optional question: Is there any aspect of the pharmacy service you received for your wound that you would like to have been different? If so, what was it and how could it have been different?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NOTE: if the wound has been present for 2 weeks or more – at the end of the interview, ask the consumer to measure the wound as per the “How to measure your wound” instructions AND arrange a time to call again in 2 weeks time to collect the two wound measurements about 2 weeks apart

Appointment details (date, time, contact number) for Follow-up call:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


Follow up for chronic wounds present 2 week or more at first interview

Date and time of 2nd interview: _ _ _ _ _ _ _ _ _ _ _ _ _ Interviewer: _ _ _ _ _ _ _ _ _ _ _ _ • Confirm the respondent’s name • Indicate you are calling to follow-up on the wound care survey the respondent completed about 2

weeks ago, when they were asked to measure the wound on 2 occasions 1. What date did you first measure the wound?

How many centimetres LONG was it and how WIDE was it? 2. What date did you measure the wound the second time?

How many centimetres LONG was it and how WIDE was it?

First Wound Measurement: _ _ _ _ _ _ _ _ _ centimetres LONG

Date measured: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ centimetres WIDE Second Wound Measurement: _ _ _ _ _ _ _ _ _ centimetres LONG


3. Have you had any further contact with the pharmacy about wound care Yes No

since the first interview?.

4. Please describe the nature of this contact.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Record relevant unsolicited comments about service quality or use of wound dressings etc.

Mystery Shopper Procedure Note time then enter the pharmacy Look around for a sign re: first aid, wound care or home health or similar Head towards that area. If no sign, head towards the professional area. 2 options - In either case, note how long it took for assistance

If you are approached by a staff member before you locate the wound care section, • ask for Melolin.

“I’m just after some Melolin for my mother, she has a bit of a sore on her leg”

If you find the wound care section without being approached by staff, browse the wound care section for 1-2 mins. • If assistance offered, ask for Melolin.

“I’m just after some Melolin for my mother, she has a bit of a sore on her leg”

• If no assistance, pick up a pack of Melolin

or other simple dressing and head for the counter. Purchase 1 dressing of Melolin (keep receipt for reimbursement)

• If assistant asks questions about appropriate product choice etc once you are at the counter, note this and start responding to probes as below

• If no extra questions asked, conclude the visit

If the assistant just directs you to the Melolin and asks no more questions or asks questions unrelated to confirming right product has been provided, pick up a pack of Melolin or other simple dressing and head for the counter. • Purchase 1 dressing of Melolin (keep receipt for reimbursement). • If assistant asks questions about appropriate product choice etc once you are at the

counter, note this and start responding to probes as below. • If no extra questions asked, conclude the visit If the assistant asks more questions or starts a discussion to check that Melolin is the right choice for the wound, make a note of the questions asked (the probes). “Mum’s had this sore on her ankle for a while now and she is just putting a grungy old bandage on it, and I wanted to get something better. Possible probes and shopper responses:

What caused wound “She said she knocked it on a chair leg” Duration of wound “its been there for a bit over 2 weeks now” Size/location/appearance of wound

its about the size of a 5 cent piece and is about 2 inches above her ankle bone” (outside of the left leg if asked) Looks a bit yellowish and weeping a bit (if asked, clear fluid)

Other risk factors for delayed healing

• “Last time, a sore like this took forever to heal” • “She’s got diabetes” (doesn’t take insulin)

The answers to all of the above probes should elicit referral to the pharmacist. • Note whether this occurs. • If the pharmacist is involved, give the pharmacist the same history given the assistant up

until that time. • Note what extra questions the pharmacist asks. • Provide the answers as per the probes above Note any advice given (and by whom, assistant or pharmacist) e.g. on better product choice, use of dressings or referral to Dr. Thank staff for advice but say you will just take the Melolin for now and discuss the advice with your mother – “she has her own ideas” • Purchase 1 dressing of Melolin (keep receipt for reimbursement). Conclude visit. Complete data recording form. Note any additional, situational factors that might affect the service experience on the back of the recording form. For 5 initial visits, 2 shoppers should record their perception of the event independently, to allow inter-rater reliability to be assessed. Example Patient history to help in preparation for the role Mystery patient: present to pharmacy to purchase dressings for mother with detail of wound below. Patient 68yo caucasian female who is overweight. Ambulant, but with some reduction in mobility. Presenting condition Ulcer on left inner ankle (size of a 5 cent piece and yellowish last time seen), has been present for about 3 months. Wants some more Melolin® to dress the wound. First presentation to this pharmacy. Medical Hx Blood pressure (sic) Diabetes Asthma sometimes Has been getting sores on her feet on and off for a few years when she is in the garden and they are always "a bugger to heal" Medication Hx Thinks takes something for blood pressure "2 puffers - a brown and a blue one" Recent Hx: Diet Traditional "Meat and 3 veg" diet - cooks with fats and butter. Not a lot of fruit - plenty of vegies though (sic) but no detail of preparation and cooking methods. Tea and toast for breakfast and snacks. Social/environmental Hx Lives alone (widow 7 years), but staying with her daughter and grandson for a while. *Need to have explanation prepared as to why daughter picked this pharmacy to visit (especially in smaller town where pharmacist might be expected to know people in the area) Performs all daily living tasks herself, no assistance (getting a bit more difficult these days).

Pharmacy ID _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Visitor ID_ _ _ _ _ _ _ _ Date _ _ _ _ _ _ _

Write additional comments on back

Recording Sheet – circle or tick box for response or describe

Was assistance before taking product to counter Yes No If YES, complete the following

• Approached before reaching wound care section? Yes No

• Time taken for assistance to be provided before product taken to counter Immediate <30 sec 30 sec-1min 1-2 mins >2min

• Assistance to find requested product? Yes No

• Did assistant ask for more information Yes No If YES, what

What caused wound Delayed healing Duration of wound Diabetes Size/location/appearance of wound

• Was the pharmacist consulted by the assistant Yes No

• Did you speak with the pharmacist Yes No

• Did the pharmacist ask you for information Yes No If YES, what


If NO assistance before the counter, complete the following

• Did assistant ask for more information at the counter Yes No If YES, what


• Was the pharmacist consulted by the assistant Yes No

• Did you speak with the pharmacist Yes No

• Did the pharmacist ask you for information Yes No If YES, what


Was any information or advice given to you about product selection etc. Yes No If YES, complete the following

• Who provided the information? Assistant Pharmacist Both

• Was information provided about: better product product use referral to GP ask patient to visit pharmacy Other

Describe the advice (eg. which product was recommended):

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Pharm ID _ _ _ _ _ _

Audit v1 1

Audit visit - Observer/interviewer data collection Date of visit: _ _ _ _ _ _ _ NB: Tape measure required

1. In what type of locality is the pharmacy? (Note: these are Bureau of Statistics categories - tick ONE box that best describes your area)

Capital city Other metropolitan centre (an urban centre of 100 000 or more people)

Large rural centre (where most of people reside in urban centres of 25 000 or more people)

Small rural centre (rural zones containing urban centres of 10 000 to 24 999 people)

Other rural area Remote zone areas

2. Where is the pharmacy located in the area? (tick ONE box that best describes your shop)

Strip Shopping centre Medical centre Major regional centre

Other specialist location _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. How large is the pharmacy?

Small (≤100m2) Medium (100-200 m2) Large (200-300m2) Extra large (>300m2)

4. Is the pharmacy in a Brand/banner group? Yes, specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ No

5. What kind of signage is there to identify the wound care area

None First aid Wound care Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

6. How many steps would a pharmacist have to take to reach the wound _ _ _ _ _ _ _ _ _ care display from the dispensary (to get around counters etc)? (illustrate any obstacles on the map requested below)

7. Draw a layout map showing the dispensary (including where it opens into the pharmacy, the location of professional products (excluding vitamins and natural medicines), the wound care section of the display and the front of shop and entrances etc

Pharm ID _ _ _ _ _ _

Audit v1 2

8. How much of the wound care display would a pharmacist be able to see from the dispensary in order to monitor it?

None Partly obscured by other fittings and could no see customer there looking at display etc Partly obscured but can see if a customer is there looking at the display Can see all or most of the display and whether a customer is there

9. Excluding tapes, bandages and sports strapping, how many linear metres of shelf space (measure the width of the facing and multiply by the number of shelves) is given over to:

(a) first aid dressings such as BandAid, Elastoplast strips _ _ _ _ _ _

(b) wound care dressings (including passive and active dressings) _ _ _ _ _ _

10. Does the wound care area contain manufacturers display/shelving aids?

not at all somewhat a lot

11. Is there any written information on wound care product selection on display? Yes No

If YES, describe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

12. Neatness and arrangement of wound care stock

(a) Are all the wound care products together? Not really (eg. interspersed with tapes/bandages and first aid) Wound products mostly arranged together Yes, well arranged

(b) Can you distinguish which products are where by looking at the display? Not really (eg. had to pull some products out to see what they were) Mostly – some hard to see/find Yes, well arranged

(c) Are there part packs of old-looking stock that might be leftovers Yes No from a particular order ie, that do not look like part of the usual range?

13. Complete the following table –for each product category, tick ONE box from each column

Product category Number of brands stocked Different sizes of individual dressings

Number of units (individual dressings)

Films none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Foams none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Hydrocolloids none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Hydrogels none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Polymer dressings none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Alginates none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Pharm ID _ _ _ _ _ _

Audit v1 3

Product category Number of brands stocked Different sizes of individual dressings

Number of units (individual dressings)

Hydrofibre dressings none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Cadexomer Iodine none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Zinc paste bandages none 1 brand only >1 brand

1 size only >1 size

<5 5-10 >10

Passive dressings none 1 brand only 2 brands >2 brands

1 size only 2 sizes >2 size

<5 5-10 >10


none 1 brand only 2 brands >2 brands

1 size only 2 sizes >2 size

<5 packs 5-10 packs >10 packs

Quality assessment For Questions 1 to 4, place a cross on the line below each question to indicate your quality or service rating

1. Overall, what do you perceive is the level of quality of wound care service provided by this pharmacy?

Poor Excellent

2. What level of wound care service do you believe is provided by at this pharmacy?

Rudimentary Advanced Basic first aid only eg. treat complex chronic wounds

3. Do the space and facilities of this pharmacy meet the needs of the level of wound care service provided at this pharmacy?

Needs not Needs at all met completely met

4. How well organised is the wound care display area to help customers self select dressings? Does not Fully assists

assist self-selection self-selection

5. Check whether the pharmacy’s wound care profile indicated that there were any written policies, procedure or forms. If so, ask to see the documents. If the pharmacy is prepared to give the research team a copy of these, take a copy or arranged to have one mailed

Sighted reported written procedures Yes No N/A No written procedures

Time taken on site to conduct this audit: _ _ _ _ _ _ _ _ _ Other comments:

C - 1

APPENDIX C – POST TRIAL INTERVIEWS The following summarises responses to the questions asked during a semi-structured interview with pharmacies participating in the pilot study. The numbers in each response correspond to the questions listed below:

12. Was the purpose of the pilot study clear to you? The aim of the pilot was to develop a self-audit package for pharmacies to assess their wound care services in a way that identified areas for possible improvement.

13. Were the materials easy to use? How could they be improved? 14. What was the most time-consuming data to collect? 15. What was the most difficult indicator to compile? 16. With the customer survey, what do you think were the reasons why customers were unwilling

to take part? 17. Which indicators, if any, do you see as useful and feasible in practice? For example, would

you repeat any of them in next year for your own practice purposes? 18. Did you see any benefits in measuring the kind of data we asked you to? If Yes, what type of

benefits and did the benefits outweigh the cost to you? During data collection, did you think about how your own practice was going?

19. Are there any changes to Point-of-sales (POS) or other electronic systems that could make the routine collection of this kind of data easier?

20. This pilot project is really the first step in the CQI (continuous quality improvement) process; if the pilot results identified possible areas for practice improvement, would you act on this?

21. Have you gained a better understanding of what it takes to do research from your participation in the project? Was the research aspect new to you? Did you get anything out of participating in research? What training or resources would have made the research process easier? In general, how do you feel about continuing with different research projects?

22. Would you do this research again? If not, why not? Pharmacy M01 - Spoke with co-owner on-site. Advanced wound care practice that includes a wound dressing service (for which a nominal fee is charged). 1. Purpose clear- could see where we were heading with the study. 2. The flow chart was useful information as it summarised the project activities well, after

the pharmacist read the whole document and need to refer back. 3. Stock count was most time consuming because of the volume. 4. Customer recruitment was difficult for a number of reasons – trust (high number of

customers who do not know the pharmacy staff well, and did not want to give out their details) and the sheer volume of people seen in the pharmacy – can’t spend extra time on recruitment when have already spent 10 minutes with customer and there is a shop full of people waiting (and the customer wants to leave anyway)

5. As above 6. One of the most interesting indicators for this pharmacy was the customer log question

about whether the pharmacy had influenced product choice (suggesting that when this did not occur, there might have been a confidence issue for staff). This pharmacy has a focus on wound care and routinely intervenes in product selection but the staff are cautious and conscious that they don’t override other health professionals as there is a risk of alienating the client and the other health professionals. This means that staff are selective with their wound care counseling. Stock count was also useful (to know stock levels). Would repeat this exercise as the stock count also helped staff to categorize dressing and so provide some informal education.

7. Did see benefits but not sure that the benefits outweighed the effort for the whole data collection. The pharmacist spent a lot of time acting as a mentor/champion for other staff.

C - 2

8. No need to change POS 9. CQI – Did not initially link this activity to CQI but said would act on any results that

showed areas for improvement 10. Increased his understanding of research and so increased knowledge and ability to

conduct self audit. Need to devote time to read materials and require commitment. Would do further studies like this if it was in an area of interest and if likely to benefit the staff (including in that are students and trainees). Doing research makes a more stimulating environment to work in and some customers might see the pharmacy in a different light because it participated in research

11. Would do this project again (see 10.) Pharmacy M03 – Telephone interview with the main contact person was a Pharmacy Assistant (also a Registered Nurse). In a second brief phone call was made to the pharmacist to discuss problems providing sales data. 1. Yes 2. Materials were straightforward 3. Stock check – have very large stock holdings as is specialist pharmacy. One of the

difficulties was that the main contact person had been on leave during the pilot and things were not done as were expected during in her absence.

4. Stock check – see above. 5. [Only 1 customer recruited – have about 2 customers for wounds/day] 6. For this pharmacy – stock holdings. As these are very large and POS not always accurate

about turnover (especially new stock in system) 7. Yes – do it all the time 8. POS – some things not registered so that they can be categorised by department and this

categorisation is not always accurate. It is very difficult to extract sales data quickly from the system as it is not good at tracking [uses Simple]

9. See above – better stock management 10. Participate in a lot of research (in past on wounds, currently on Methadone, etc) so quite

familiar with methods, etc 11. Yes Pharmacy M04 - Spoke with owner – wound care practice quite advanced; the pharmacy had a broad range of stock due to community nursing contracts 1. Objectives, tools and processes clear; not too long winded. Felt that the time required to

do the data collection was understated. 2. Materials easy to use, and the glossary helpful in categorising different products. The

materials completed by the pharmacy could have been improved if the depth of the range rather than the volume of sales had been collected. The pharmacist felt that this was a better indicator of service quality. [advised that these were collected by audit visit]

3. Stock sales was most time consuming 4. Stock sales since no help from wholesaler and systems did not really facilitate this. In

their POS, sub-categories for wound care products did not exist. The ability to provide this information would depend on how well POS was sub-categorised. Note that since supplied community nurses, there was a lot of stock held.

5. Customer recruitment was also difficult. It was difficult to focus on this because of the timing of other events such as PAN pharmaceuticals, key personnel being away and other priorities. Keeping staff motivated and committed was very difficult for the pharmacist and very time consuming.

C - 3

6. Indicators that told of depth of range were most useful eg. the dressing categories in stock. A indicator that looks at merchandising (how section arranged eg. Random, grouped by type or alphabetical or company) could have been a good indicator of service level – grouping by type or function would suggest a higher service level.

7. Not a lot of benefits but did identify that merchandising in the store could be improved. There were issues with the pack sizes and presentation of products not being retail oriented, so that it is difficult to merchandise and make it look tidy, even with shelf adjustments. A novel way is needed to store wound care products. The pharmacist would need to think about this. Overall, probably didn’t outweigh the costs as yet but this may change when get feedback report. Also unlikely to repeat any indicators on their own.

8. POS – no change 9. Would use pilot as a CQI activity but needed researchers to point out that the project was

potentially CQI if pharmacists reflected on finding of the audit etc. 10. Mentoring is important – the distance from the researchers meant that the pharmacist had

to spend more time to sustain staff commitment and that this wasn’t always consistent, therefore there was decreased commitment. There needs to be close contact with researchers to sustain motivation. Face-to-face sessions with the researchers might have been helpful to increase staff motivation. Should also consider identifying 2-3 key staff (assistants and others) to give ownership of the project because this project needed direct involvement of the front of shop staff. Perhaps consider prizes or other incentives for the quiz (note that use of the term ‘quiz’ was less threatening to staff; it was promoted as ‘fun’ giving a higher uptake. A prize would increase this feeling of ‘fun’).

11. May not do project again due to the time involved. Pharmacy M05 – Telephone interview with pharmacist 1. Yes, think so but didn’t really see any wounds 2. Materials easy – log very easy to use. POS could be improved to generate information

though, needs to be categorised for wound products groups 3. Time consuming – statistics of stock sales. 4. No recruitment as saw no wounds – often people buying dressings for another or first aid 5. Useful to look at the log and see what people came in for 6. See above 7. Benefits outweigh costs (especially if POS improved) 8. See above 9. Yes – would act on it as QCPP accredited 10. Have a culture of participating in research in this pharmacy. Log easy to use and

important. Realise types of wounds seen and need to improve stock to meet the customer needs. Happy to generate stats if easy to get from computer

11. Yes Pharmacy M06 – Telephone interview with pharmacist, not owner 1. Yes 2. No problems filling things out 3. Sales data most time consuming 4. None were too difficult 5. 6. More interested in the treatment of the patients – felt their treatment was OK 7. Useful as going for QCPP accreditation 8. Don’t use POS 9. Yes

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10. Not very involved in research – generally too busy but thought this important. Understood what was needed

11. Yes – the staff gained from participating in it Pharmacy M08 – Telephone interview with the pharmacy assistant most involved with the project and a later brief call to the owner on difficulties in getting sales data. 1. Study purpose clear 2. All documents were OK except for the stock turnover form which was a bit confusing 3. Stock orders most time consuming 4. Stock orders difficult to compile; not recruit as too busy and patients not keen (large

ethnic and lower socioeconomic demographic) 5. See above 6. Stock check was good to look at stock levels as don’t really go to the section unless a

customer needs something 7. Benefits were increased product knowledge gained while doing stock check 8. Didn’t use POS – trawled through sales histories. The owner was going to try and

approach the wholesalers for this information. 9. Yes – knew was a CQI activity 10. Useful to understand a bit about research. Research in general is new to this pharmacy

and appreciated the personal approach – felt comfortable to ask questions 11. Yes Pharmacy M11 - Spoke with owner on the telephone (who was just completing instruments in the 30 minutes between two follow-up calls). 1. The purpose of the study was reasonably clear as were the materials especially the

glossary that showed how to group the different stock 2. The materials were easy to used but it was very difficult to collate the amount of

information within the time frame requested. 3. Stock data was the most time consuming [note that sales data was not provided] 4. As above 5. Claimed to have no problems with the ‘customer survey’ with customer accepting

recording of their purchases [the pharmacist mistook the customer log for the customer survey – this site did not recruit any customers for the survey]

6. Doing the stock analysis to see where the sales were (via log) was useful and grouping stock by category was a form of education. The pharmacist felt there was a need for staff education and that this education had to be at a level and using concepts that were suitable for the type of work done (eg. different education for assistants and pharmacists). Wound care was a complex market and there was a need to prepare people to handle it, including an innovative way to educate staff. Felt that it would be hard work to get company support for this since the sessions needed to be two 20-30 minute sessions run for a few staff members at a time (to keep the floor running). The stock holdings was most beneficial – it forced “you to look realistically at what you’ve got and you realise that you don’t know what stuff is for”. It identified areas where staff needed more confidence. The pharmacist felt the need for decision support tools to aid the best selection of products for customers. Charts needed to be at staff fingertips and to be clear and simple, but supported by education).

7. The benefit of the project was that it forced the pharmacist to look at this area. It has given him something to think about and he realised that the area was not as efficient as it could be. The area need education to support it.

8. [not asked]

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9. Definitely would follow up on practice improvements – the pharmacist noted that wound care stock was “bought rather than sold” through customer self-selection and that education was needed to give the confidence to ‘sell’ dressings.

10. Yes – new ideas on research, that it makes you think about your practice 11. Yes The pharmacist reflected generally on wound care education. He felt that more education was needed for pharmacists as well as staff, that this was part of their professional training and it needed to be easier to update. The whole industry had moved so that sales spiel was too product oriented where staff needed an overview (although the pharmacist recognised that reps weren’t paid to give education). A course like the eye care program for the pharmacy college (run over 3 weeks for 2 hours 1 night/week) that addressed the various types of processes of care would be ideal. Pharmacy R01 – Spoke to owner by telephone on second occasion (driver of the pilot) and employee pharmacist and staff initially (on site). Initial comments came from employee pharmacist with only peripheral involvement in the project. The employee pharmacist and staff reported that taking part in the project was awareness raising in that they took notice of the stock carried and what the products were for. The pharmacy had a broader range of stock because of its role in serving the local community. In the community, the trust customers had in the pharmacy made it easier to sell the new, more expensive dressings over less costly, less effective older dressings. 1. Yes, the aim was clear. 2. Yes, materials were clear and easy to use. The glossary was a refresher in terms of

product category and was very helpful in filling out the forms by dressing category. 3. Sales data was the most time-consuming (the pharmacy has POS but it still took time to

collate) 4. Recruiting people for the survey was the most difficult since the staff needed to word it in

a non-threatening way. Customer surveys were a new concept to the pharmacy and their customers.

5. See above. The flow of customers was up and down in the 2 week window which made recruitment a bit more difficult. The pharmacist noted that knowing the customer makes a huge difference to the likelihood of recruitment and allowed the pharmacy to pick the right customers to involve (who could handle a phone call from an unknown person or who were not cognitively impaired). Thus the pharmacy selected customers for the survey rather than consecutive customers. The survey as follow-up for outcome would be more viable if the pharmacy did it (since could be done at successive visits)

6. The stock review was the most useful, since it was relevant to update the stock and to keep the right level of stock.

7. The project highlighted the fact that the pharmacy did not document stuff and that this should be done (follow-up was generally oral and not recorded). It also gave an appreciation of what sales were of the various dressings. The project highlighted the need for training - all staff (including pharmacists) were grasping for further education about wound care. Staff liked the area but their confidence level was low. If they had more confidence, they would take on more with gusto but currently, they realised they could get up to a certain stage then got out of their depth. To some extent, there was a burden to educate customers about what to expect and to change their attitudes about wound healing. The pharmacist also commented that customers appreciated the staff interest in their wound progress and customers were willing to take advice, so that it changed their view of pharmacy practice. The project was good PR and helped the professional aspect of the service.

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8. Yes, need to refine that department of the pharmacy – this is an internal thing done by the pharmacy. The project highlighted this aspect and the pharmacist is considering linking wound care products and making the category information better.

9. Yes 10. Yes – the project conveyed the idea that a ‘no result’ is still information that can be used

in this type of research. This wound project was timely since it came shortly after a local wound presentation by an expert. For this type of project, need to get the whole team interested, and, since all staff feel lacking in current knowledge, training prior to the project would drive the project further and increase interest and participation. Similar small projects in special areas were likely to be helpful.

11. Yes but being able to focus on was difficult. The pharmacist also discussed merchandising problems displaying dressing since there were no ‘hand-sell’ units and products were not uniform sizes (although some companies had made promises in this area). There were also service problems with the merge of Beirsdorf and Smith & Nephew – it was more cumbersome for customers (the pharmacies) and that the merger meant that no rep called currently. Pharmacy R02 - Spoke with the owner on site In initial discussions, the pharmacist indicated his beliefs that wound care is a really important area and their practice is the tip of the iceberg. 1. Purpose was clear. Like the idea that the outcome was that it could provide standards for

wound care [in pharmacies] 2. No problems, everything was clear. The pharmacist helped the assistants (as a mentor) 3. Nothing was particularly time consuming. Hadn’t yet done sales but did not expect it to

be time consuming because can easily generate reports from POS 4. No difficulty to instruments etc, but spoke about problems recruiting customers for the

survey (time pressures). Noted that patient trust in the pharmacist was important for recruitment [this pharmacy recruited the most subjects for the customer survey, although some did not meet eligibility criteria], and that their local relationships with customers were very good.

5. The timeline was a problem because of other demands on time (PAN pharmaceuticals, school holidays etc). The mentoring of staff was important but took a lot of time.

6. Didn’t really see direct benefits but the project made staff more aware that bandaging and dressings should be treated differently to other areas of the shop. Overall, the benefits did outweigh the costs

7. POS – he fed information in (downloaded from wholesaler in their category) – it would have been better if searchable by supplier to find stock items

8. CQI – Will use as a CQI activity and would act on outcomes from the pilot if areas for improvement identified

9. Gained a better understanding of research – did not find it as onerous or as scary as it first seemed (when the envelope arrived). Would have been helpful and wound have been less intimidated if there had been an introductory workshop/seminar about the project and research in general. Such a seminar would have raised the level of enthusiasm in staff. The need for the pharmacist to keep enthusiasm up (act as project champion on site) was time consuming, since the ‘girls needed to be coaxed along’.

10. Got a real sense of satisfaction from the project and would do other research. For the pilot audit, the timeline was too tight [actually 8 weeks] but it the audit would be OK if the pharmacy did it at its own pace (say 2-3 months)

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Other issues raised in discussions were the high cost of products (particularly with the rural downturn associated with the drought), packaging and display of products (some not user friendly) and that it was hard to keep up with product changes. Pharmacy R04 – Site had not really started at time of visit in early June. Since then, owner has been hospitalised. Interview was carried out by telephone later. 1. Yes, clear 2. Materials were not difficult but the timing was unfortunate (ill health of owner, holidays

and Pan Pharmaceuticals recall). The idea of the project was good, and it was good to see research being done.

3. Stock sales was likely to be most time consuming – this was not done since ran out of time. Computers were not an enabler here since need to configure ad hoc reports, which was not easy in the timeframe – can get a big report but would then have to go through it manually.

4. Stock sales 5. None recruited – pharmacist did not know if any customers were asked or if any refused 6. Would go through the exercise again since always need to revise stock versus sales. It

would depend on the staff enthusiasm. The pharmacist felt that a change in customer attitude was needed since it was difficult to persuade customers to use new, more expensive products.

7. Saw no immediate benefits but is sure will see some benefits when reports come back. Hypothetically outweighs cost. The project was awareness raising, particularly since there was a seminar by a visiting wound care expert about the same time. Putting stock into categories per the glossary and the data collection forms was also helpful.

8. See 3. Uses Lockie POS and LOTS dispensary system 9. Yes 10. Yes. The resource needs mentioned by the pharmacist related to tools for the provision of

wound care services, rather than tools for research in general. 11. Yes Pharmacy R05 - Spoke to owner on site. Note that this is a pharmacy committed to service quality and quality improvement, and was undertaking QCPP accreditation at the time of the pilot study. The pharmacy experienced some human resource pressures during the pilot because 1 key person (pharmacy assistant with wound care experience) was away. In this sense, the pilot highlighted the pharmacy’s dependence on that key person. The customer log also identified that people came to the pharmacy on the weekends and later in the afternoon when the key person with wound care knowledge wasn’t present. While the staff were reported as being ‘really keen’, the pilot also took quite a lot of the owner’s time to train up staff about what was required. 1. Yes in terms of both steps and the goals 2. The log was easy but other paperwork needed to be streamlined eg. consenting for

customer survey (not needed to the same extent if the survey was to be conducted by the pharmacy itself)

3. Recruitment – fruitless, customer follow-up always difficult 4. Most difficult was stock level information compared to completing the customer log

(which was easy). Customer survey was difficult since it needs time to explain to customer (the ethical requirements on the consent sheet makes some customer baulk) and they need to make time to do the interview (some unwilling). Also, pharmacy assistants lacked confidence to broach the subject with customers. Assistants also concerned that if they did get customers for the survey, the lack of assistant skills would show up. There

C - 8

might also be a fear that the quizzes might show up inadequacies (NOTE: this site did not return any quizzes).

5. See 4. above 6. Stock management most useful – the pilot was the first time they had looked at the range

of stock carried. The owner would consider repeating this exercise 7. There was quite a bit of time involved since the staff were not used to collecting data.

With training to collect data, the staff could embrace the audit. The audit was still worthwhile (see above) but there were also unexpected benefit in that it was good PR (public relations) for the pharmacies. It looked good to customers that the pharmacy participated in research and seemed to be at the cutting edge of practice. A range of areas for improvement were identified (see customer presentations versus availability of trained staff, above) such as the need to assist customer self-selection of dressings, a check that the right range of dressings were stocked.

8. POS – like to have a better ability to better categorize products on POS but this would be an in-house task (not software provider) to set up categories. The problems with the POS (Simple) was that the categories didn’t match the area and that it was less easy to get ad hoc reports, although this might be need better understanding of the system by the pharmacy (which would take time that is in short supply!). Getting wholesaler’s to give a breakdown of sales was not considered to be very user friendly since there were too many items to list individually - wholesalers didn’t seem to use related categorisation of products and previously, the pharmacy had to ask for purchases of a specified item.

9. CQI – had not seen the pilot as a CQI activity but in the subsequent discussion, pharmacist gained some good ideas

10. Gained a better understanding of research especially through the mentoring that was used in this project. The face-to-face discussions with research staff were very useful to improve this study. The interactions also stimulated more interest in other research or CQI possibilities in house.

11. Very enthusiastic – would like to be more involved as it makes the whole practice more interesting and, importantly for a country pharmacy, the focus on practice made the pharmacist feel more connected to the bigger picture. For future studies, strategies to engage the whole staff and where the staff can drive the project (rather than the owner) would be helpful. If the site did such an audit again, they would prefer to do it at their own speed (but within 2 months).

In further discussion about the customer survey, the pharmacist said that it was a ‘sound idea’ to follow-up customer wound healing but that staff needed to be better trained to give the right advice and how to address an issue if the outcome was not positive. The pharmacist felt there needed to be better care protocols to link with customer follow-up, and that the pilot materials would need some modification if customer follow-up was done in-house. Other issues arising in the discussion related to the need to have product information printed on the boxes of products and issues related to the costing of stock (especially dealing with the large pack sizes in which some products are only available). Pharmacy R06 - On site interview with pharmacy assistant who was the main person who ran the pilot at this site. While the owner was supportive, both the owner and the pharmacy manager had minor involvement in the project. 1. Clearly understood the purpose of the study 2. Didn’t really use the instruction sheet but relied on the face-to-face verbal communication

from the researcher visiting the site. Found amount of text daunting and would have preferred a summary/important point sheet.

C - 9

3. Nothing overly time consuming 4. Most difficult to recruit customers – felt that patient recruitment depends on trust but the

only customer given consent form did not return this to the pharmacy and was not followed up. Another problem was that it was difficult to keep customer log when the pharmacy was busy and when assistants were lined up at the till.

5. Couldn’t really identify which indicator most useful but thought materials would be useful for a new pharmacy to get an idea of their customer base and order needs

6. Maybe increase awareness of wound care and may have learned more about wound care because of it

7. POS changes might have been useful but not really relevant to them as they only have one register

8. CQI – would act on areas for improvement if identified 9. Definitely gained better understanding of what research is about. Overall because

focused on the location, more aware of ordering and increased overall awareness of wound care. Like to see minimum paper work and seminar or workshops to introduce the project. The face to face contact with the researcher as a mentor was most helpful. Pharmacy assistants need important facts, quick and targeted information with a service perspective (fitting in with what they do). They need to know what the information is for. The research and the topic should be interesting/relevant to them.

10. Yes, would do it again. Felt that it was important that everyone should be involved, not just one person running it – it should be a team function.

Pharmacy R07 – Telephone interview with the pharmacy assistant who was the main person who ran the pilot at this site. Note that the original contact person left, leaving the pharmacy short-staffed, and the pharmacy assistant who was ultimately interviewed took the project over. She, in turn, became ill and so data collection was delayed (only the customer log was completed). While the owner was supportive, he basically had little or no involvement in the project. The locum pharmacist was not involved. 1. Yes, it was well explained (in materials and in face-to-face discussions with researcher) 2. Yes 3. Stock would have been most time consuming 4. see above 5. Reported that it was too hard to recruit customers 6. Sales (per log) and stock sold most useful since it defined customer base 7. The benefit of the project from the pharmacy assistant perspective was that it cause the

staff to focus on wound care. Highlighted that staff needed more training in first aid and wound care, especially in product selection and how to use the products so they could assist customers without always having to refer to the pharmacist. The pharmacy assistant felt that education was needed to build confidence but that present training methods/seminar were too quick and over the heads of assistants, and that the training did not tap into what assistants need to know. Materials were too technical about how wound heal. Training needed to start with the basic service needs (to be able to differentiate the products for the customer) before moving onto the detail. Practical mentoring, a form of in-house training by a person trained externally would be a good approach (ie. Run a wound care train-the-trainer course so that the trained person can then train other staff on site).

8. N/A 9. not asked 10. not asked 11. not asked

C - 10

Pharmacy R08 - Spoke on site with the employee pharmacist who championed project, and with a pharmacy assistant in a later, brief telephone call. 1. Purpose was clear but was unsure about getting started. Staff training about the project

would have been useful in generating commitment and enthusiasm 2. Instructions clear and found the list of example essential eg. How to calculate stock

figures etc and just what dressings belong to which class. The instruction sheet showing types of wound dressings increased product knowledge in itself.

3. Stock count most time consuming 4. Stock count, since it took the pharmacist out of the dispensary and even then got

interrupted regularly. The up side was that the task could be scheduled at a time that it suited the pharmacy (eg. Late afternoon). Even though the stock count was difficult, it did have benefits. As a summary report, the customer log was useful to compare with stock holdings. Overcame queuing for the customer log when the pharmacy was busy by generating a duplicate till receipt and completing the log later.

5. A lot of customers with wounds would have struggled to take part in telephone interviews because of decreased cognitive function, so the pharmacy was very selective in who they approached to recruit for the survey. Also difficult to recruit because customers saw no benefit from participation. Pharmacist said that had the survey been conducted face-to-face in the pharmacy, it might have been easier. Another issue was the time investment in serving a customer and the unwillingness of customer and staff to spend even more time on 1 customer to go through the consenting process.

6. Can see potential benefits but will have a better idea when the feedback report comes out. Overall benefits seen in terms of awareness-raising among staff about wound care. Sorting the stock in to categories had an education component for the staff and was most useful and the pharmacist thought the customer log was the best bit. A staff member said that in filling out the log, staff took an interest in what people were buying for what purpose, and that this was educational.

7. POS - might have been useful being able to flag purchases of wound products for recruitment but generating information from existing POS was OK.

8. Aware of CQI process but did not directly link pilot as part of this initially. Would act on areas for improvement if they were identified by the pilot report.

9. Did gain a better understanding of research – identified the need for research in community pharmacy to fit in around the job

10. Would do the project again provided it could fit around the job.

D - 1

APPENDIX D – ETHICAL APPROVAL Letters of ethical approval • Princess Alexandra Hospital research Ethics Committee • University of Queensland Medical Research Ethics Committee

E - 1

APPENDIX E - MATERIALS FOR FINAL EXPERT PANEL MEETING AGENDA FOR WOUND CARE EXPERT PANEL MEETING, 30 JUNE 2003

WOUND CARE EXPERT PANEL MEETING

Monday 30th June, 2003

Time: 1.30p.m.

Venue: Conference Room, Centre for Health Research

2nd Level, West Wing, TAFE 3 (Building 35) Princess Alexandra Hospital

Agenda

1.30pm Welcome and introduction of participants Apologies

1.40pm Presentation on project to date 2.40pm Discussion of findings and development of possible

recommendations 3.20pm Conclusion

Apologies

1. Sandy Wainwright 2. Matthew Cichero 3. Greg Duncan 4. Stephen Yelland

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MEETING SUMMARY The meeting began at 1.30pm with apologies and introductions. Present were: Ms Tania Parisi Smith & Nephew, representing MIAA (Medical Industry

Association of Australia Wound Care group) Ms Dianne Cunningham Wound care Specialist Nurse, Bluecare, Mt Gravatt Dr Harry Gibbs Associate Professor of Medicine & Director,

Vascular Medicine Department Princess Alexandra Hospital

Ms Kathy Kendall Consumer representative Mr Pete Marcus Manager IT Programs, National Secretariat,

The Pharmacy Guild of Australia Ms Michelle Bou-Samra Community pharmacist, Pharmacy Guild of Australia (Qld

Branch) representative Ms Sue Scott Community & hospital pharmacist, Pharmaceutical Society of

Australia (Qld Branch) representative Ms Barbara Sponza Consumer, Diabetes Australia (Queensland) Mr Geoff Sussman Wound care pharmacist, Director, Wound Education and

Research Group, Monash University Dr Julie Stokes Investigator Professor Michael Roberts Investigator Dr Sheree Cross Investigator Mr John Chapman Investigator Apologies were received from Ms Sandy Wainwright, Mr Matthew Cichero, Mr Greg Duncan and Dr Stephen Yelland.

PRESENTATION OF FINDINGS TO DATE AND DISCUSSION

Dr Julie Stokes gave a presentation of the findings at the time of the meeting. The presentation images are shown in order on the following pages (read slides left to right then down) although relevant discussion is includes to the right of certain images.

Wound care benchmarking

Measuring wound care service quality in community pharmacy

Wound care benchmarking

Measuring wound care service quality in community pharmacy

Expert panel meeting30 June 2003

Methods & ImplementationMethods & Implementation

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Characteristics of sitesCharacteristics of sites

R01R04R07

M01 M04M08

Strip>200Other

R05R06

M03Other

R02R08

M05 M06M11

Strip<200RuralMetroTypeSize m2 Other sites –

1 shopping centre; 1 medical centre; 1 stand alone3 banner grp – lower than national rateSmaller pharmacies under-represented cf national patternRecruitment issues

6 withdrawals

Indicator data collection PlanIndicator data collection PlanDay 0

Day 1

Timeline

Day 14

Day 55

Day 17




Purchases History

Start Customer log

recording










Day 27

Audit visit

Mystery shop

Telephone survey 1 & 2

Not done

Current receiptsCurrent receipts

Achieved with onsite visit to explain materials, repeated phone calls once underway & 2-3 other visits Problems with staff changes or key people away

ID Number M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08 TotTasks completedAudit Mystery shoppedProfileCustomer logStock holdingsSales/purchase Hx nd8 week salesNumber transactionsPatients recruited 1 1 2 1 3 6 1 15Patients responding 0 1 1 1 2 3 1 9No. pharmacists 4 3 3 1 2 2 2 2 2 3 2 1 2 29No. assistants 1 4 6 3 3 2 6 5 6 7 5 5 6 59Quizzes sentPharm Quizzes returne 4 3 1 1 2 2 2 15Assistant Quizzes retur 1 3 3 1 4 3 6 21End of trial interview

Assessment of quality indicatorsAssessment of quality indicatorsDevelop independent quality measures & check reliabilityAggregate indicator data*Compare indicators with other indicators*

Quiz vs trainingStock vs salesStock vs wound typesStock from audit vs stock from self-report

Compare potential indicators against independent quality measures*

Since pilot, consider significance at p<0.1

Assessing quality independentlyAssessing quality independently

Independent quality measuresIndependent quality measuresAudit visit by wound care specialist pharmacist - 4 global assessment scales:

Overall quality – poor to excellentLevel of wound care service – rudimentary to advancedSpace & facility needs met for level of service – not at all met to completely metOrganisation of wound care display to help self-selection – does not assist to fully assist

Mystery shopper global ranking & score

Mystery Shop ScoringMystery Shop ScoringHad product = 1 pointNo assistance at all = 0 Any help = 1 pointSomeone (assistant or p’cist) sought more infoon wound = 1 No info sought = 0For each type of assessment info = 1(5 possible categories)Referral to or consult with p’cist = 1 None = 0Any wound care advice given = 1 No advice = 01 point for each separate piece of advice on product or wound healing (max 6 points)Possible Range 0-16

It seems that pharmacies need good shelf stock as there was very little assistance received from staff. This suggests that a minimum standard should be a sign outlining the basics of product selection, however Geoff Sussman said that this could be dangerous if the customer picked the wrong thing. There was then discussion about whether some advice/guidance was better the current situation where none was available (possibly due to pharmacy assistant reluctance).

E - 4

Mystery shop info & adviceMystery shop info & adviceInfo sought

3 x Size/location/appearance of woundDuration of wound (volunteered)

Mystery shop advice given2 x Need tape to adhere Melolin2 x Apply shiny side to woundEconomy - Buy larger & cut to size; cost box vs singlesDiscussion on whether needed waterproof dressing (scored as advice not information seeking)

3 sites sought info & gave any adviceShopper at wound section ignored by PAs 2x

Mystery shop score vs rankMystery shop score vs rank


76543210

Mys

tery

sho

pper

rank

ing

16

14

12

10

8

6

4

20

R08

R07

R06

R05

R04

R02

R01

M11

M08

M06

M05M04

M03

M01

Spearman’s correlation coefficient = 0.876 (P<0.0001)

Audit vs Mystery shop qualityAudit vs Mystery shop quality


100806040200

Mys

tery

sho

pper

rank

ing

16

14

12

10

8

6

4

20

R08

R07

R06

R05

R04

R02

R01

M11

M08

M06

M05M04

M03

M01

M04 – busy shopM03 – assistant not busy but pharmacist was


100806040200

Mys

tery

shop

per s

core

9

8

7

6

5

4

3

2

10

R08

R07

R06

R05

R04

R02

R01

M11

M08

M06

M05

M04

M03

M01

Max possible shopper score revised to 9 max info actually sought & given

* Shows line of unity

Limitations of a single mystery shop episode were discussed since the shopper may not get the ‘right’ pharmacy assistant or the shop may be busy.

Independent quality scoreIndependent quality scoreAudit overall quality +(Mystery shopper rank + score) x100/30

Maximum 200 & min 3.3Accounts for single mystery shop

Spearman’s rho (n=14)

Myst. Shop

rank 0.876 Myst. Shop

score p<0.0001 Myst. Shop

score 0.326 0.219 Audit overall

quality level p=0.255 p=0.452 Audit

overall quality

0.727 0.663 0.824 Independent quality score p<0.004 p<0.01 p<0.001

The independent quality score combined the mystery shopper and audit visit ratings to reduce the impact of a single, unrepresentative mystery shopper visit.

Independent quality measure correlation

Independent quality measure correlation

Spearman’s rho Myst. Shop rank Myst. Shop score

0.326 0.219 Audit overall quality level p=0.255 p=0.452


0.480 0.393 0.905 Audit level of wound care service p=0.082 p=0.165 p<0.0001

0.345 0.262 0.618 Audit Space & facility needs met p=0.227 p=0.365 p=0.019

0.522 0.402 0.811 Audit Display aids self-selection p=0.056 p=0.154 p<0.001

Types of wound seenTypes of wound seenWound type (% of customers) Site No.

cust None (for future use)

Cuts and grazes


Stitches/ surg. wound

Other Don't know

M01 19 32 26 11 11 11 11 M04 24 38 21 21 13 8 M05 9 33 11 44 11 M06 29 24 28 24 10 7 17 M08 4 25 25 25 25 R01 12 8 8 8 42 17 17 R06 15 7 40 7 13 33 R08 22 5 23 5 18 23 18 5 Site Algin

-atesCadex-omer iodine

Films Foams Hydrocolloids

Hydrogels

Other related product

Pass-ive

Poly-mer

Scar re-

duction

Simple first aid

Tapes & band-

ages M01 7 4 4 4 19 26 15 22 M04 3 6 17 6 6 6 6 19 11 6 17 M05 9 18 27 45 M06 29 2 2 24 7 27 9 M08 20 60 20 R01 8 15 15 54 8 R06 15 15 8 38 23 R08 19 4 67 11

E - 5

Customer log activitiesCustomer log activities% customers Site

Customers influenced

Changed cust choice

Referred on

Pharm. Asked

M01 89 89 11 74 M04 67 17 0 38 M05 56 33 0 22 M06 52 21 24 17 M08 0 0 0 0 R01 50 0 0 33 R06 87 60 7 7 R08 55 23 18 36

‘Referred on’ was clarified as to other health professionals. The types of wound care seen varied, with requests being a combination of product and symptom based requests. Tania Parisi indicated that Smith & Nephew data indicated that pharmacies saw a lot of cuts and grazes.

Relationships between indicatorsRelationships between indicators

Shop sizeShop sizeShop size >200m2 more 1st aid shelf metres (median 3m vs 1.8) p=0.019

Due to rural rents?Total shelf space related

No relationship for shop size & wounddressing space orrelative % of dressingshelf space for woundcare Size of pharmacy

5.04.03.02.01.00.0

She

lf sp

ace

for f

irst a

id d

ress

ings

(m)

18

16

14

12

10

8

6

4

2

0

Rural

Metro

Turnover from wound stock is generally low but it takes up a lot of space. This was related to store size for first aid dressings John Chapman suggested shelf space may be related to prescription numbers

Other intra-indicator relationshipsOther intra-indicator relationshipsThe more wound care shelving, the further the pharmacist has to walk to reach it from the dispensary (rho=0.576 p=0.031)All profile quality ratings correlated except for display arranged to assist self-selection As p’cists rate quality & level of service higher, rate space & facility needs as less met

Indicator relationships with independent quality measuresIndicator relationships with

independent quality measures

E - 6

Audit vs self-reported qualityAudit vs self-reported quality

Profile overall service quality

120100806040200

Aud

it ov

eral

l ser

vice

qua

lity

100

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Profile service level

120100806040200

Aud

it se

rvic

e le

vel

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Poor Excellent Rudimentary AdvancedBasic 1st aid treat complex wounds

M06M06

* Shows line of identityrho=0.812 p=0.050 n=6

The Panel noted that the auditor and the proprietor could reflect a different marking strategy between the two. It was not known how reliable the audit ratings were as these were not checked for inter-rater reliability Mike Roberts commented that rural and metro pharmacies may need different information or standards due to differences in customer relationships

Audit vs self reported qualityAudit vs self reported quality

Profile space needs

100806040200

Aud

it S

pace

& fa

cilit

ies

need

s

100

80

60

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20

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Profile display aids self-selection

100806040200

Aud

it di

spla

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ds s

elf-s

elec

tion 100

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Not at all met Completely met

R08

M05R08

Does not assist Fully assists

* Shows line of identity

Self-report quality vs mystery shopSelf-report quality vs mystery shop


1614121086420

Pro

file

over

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ervi

ce q

ualit

y

120

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80

60

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0

R08

R01

M06

M05

M04

M01

Mystery shop score

9876543210

Pro

file

over

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ualit

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120

100

80

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R08

R01

M06

M05

M04

M01

Max possible shopper score revised to 9 max info actually sought & given

* Shows line of identity

Self-report vs independent qualitySelf-report vs independent quality

Profile space & facility needs met vsaudit service level rho=-0.829 p=0.042 n=6

Profile service level

120100806040200

Inde

pend

ent q

ualit

y sc

ore

200

180

160

140

120

100

80

60

40

200

R08

R01M06

M05

M04

M01

Profile space needs

100806040200

Inde

pend

ent q

ualit

y sc

ore

200

180

160

140

120

100

80

60

40

200

R08

R01

M06

M05

M04

M01

rho=0.812 p=0.050 n=6 rho= -0.771 p=0.072 n=6

Indicator – Signage & Banner GrpIndicator – Signage & Banner GrpRelated to audit space& facility needs met (p=0.076) and self-selection rating (p=0.027)

Banner group (n=3) had lower mystery shopper score (p=0.017) median 1 versus 4 in non-banner grp

Display for self-selectS & F

753731

58Wound care35First Aid17No sign

Median rating

Shelf space vs qualityShelf space vs qualityShelf space for wound dressings rho=0.582 p=0.029% of dressing shelves for wound care (n=14)

Independent quality score rho=0.466 p=0.093Audit overall service quality rho=0.594 p=0.025Audit service level rho=0.587 p=0.027Audit display self-select rho=0.477 p=0.084

Shelf space vs qualityShelf space vs quality

% of total dressing shelf for wound care

100806040200

Inde

pend

ent q

ualit

y sc

ore

200

180

160

140

120

100

80

60

40

200

Pharmacy size

>200 sq.m

<200 sq.m

R08

R07

R06

R05

R04

R02R01

M11

M08

M06

M05

M04M03

M01

>200 m2 only then rho = 0.700 p=0.036 n=9

Finding: % of shelf for wound care only important in larger pharmacies

E - 7

Quality & % wound care shelvesQuality & % wound care shelves% of dressing shelvesfor wound care seemsto be quality indicatorin city but not in rural areas

133 133N =

Independ. quality category

AdvancedMid rangeBasicW

ound

car

e %

of d

ress

ing

shel

ves

120

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-20

-40

95%C

Metro

Rural

Stock range does not = qualityStock range does not = quality


200150100500

Sto

ck ra

nge

scor

e

64

56

48

40

32

24

16

R08

R07

R06

R05

R04R02R01M11

M08

M06

M05

M04M03 M01

Process & other qualitative dataProcess & other qualitative data

Time taken for data collectionTime taken for data collectionQuiz p’cist median 9 mins (range 4-30)Quiz PA median 5 mins (2-10)Profile median 30 mins (30-60)Current stock holdings median 60 mins (60-120)Purchase/sales data median 53 mins (30-180Audit approx 20 minsCustomer recruitment & survey ??

Data collection took a long time in some pharmacies since they do not routinely collect data and systems (POS etc) are not in place to facilitate data collection and these would need a lot of work to make them so. Pharmacists tended not to look at these kinds of patterns in data. Mike Roberts suggested that there was a problem of investment in systems/training/financial and IT to record such data e.g. where POS not linked to the dispensary or only being used as a glorified cash register.

Post trial interviewsPost trial interviewsSeen as interesting & useful as focused attention on this category

Review of stock holdings in categories most useful for all except benchmark site (more interested rate of influencing purchase)

Not difficult to compile data but time consuming

Since not routinely collecting stock/sales dataDaunting until had on-site introNot much use of POS for these types of purposes nor saw how this would help

The customer recruitment was classed as the most difficult part for pharmacies. The panel suggested that this might have been easier if the pharmacies had got into the spirit of wound care follow-up with customers.

E - 8

Post trial interviewsPost trial interviewsEducation for assistants needs to be improved

Rural sites &/or those with low turnover miss company educationNeed simple tools to help staff give better service e.g. product selection & information seeking

Pharmacist education/confidence issues Empower PAs so study runs without continual direction of pharmacist

Need to have a team to run the project not just 1 person

The sites commonly complained of the lack of education and limitations to access. Geoff Sussman disagreed and said that education was available. Julie Stokes said that the issue for pharmacy assistants was also one of the complexity and relevance of current education to the way pharmacy assistants work. Staff wanted protocols with short steps they could follow, so that they could improve step by step rather than being put off by high level, complex training.

Most pharmacies wanted simple education and they didn’t want to pay for it. The panel felt that there was some basic wound care content that had to be learned and that any basic process to aid product selection would be dependent on this. But basic selection tools were required. Geoff Sussman indicated that in the next Australian Pharmaceutical Formulary (APF), all the dressing types and who makes what will be included. Members of the panel were concerned that making things too basic would lead to the provision of an inappropriate product or advice that had the potential to do harm. Julie said that the mystery shopper program showed that at present, no substantive advice was being given, and that surely something was better than nothing. Mike Roberts said that this was an issue of process versus content – staff need to know how to interact with the customer to start a dialogue about wound care, but the current process was such that the consumer was not getting advice.

Post trial interviewsPost trial interviewsIdentified need for better

Stock control/managementMerchandising (product display etc) in a disease state management contextCommunity pharmacy friendly packaging incl. info on product use on each unitStaff protocol for service episode

Hadn’t thought of project as CQI

The lack of information on how to use a dressing on each dressing unit needed to be addressed. Tania Parisi indicated that dressings were made overseas for the global market, and mostly aimed at use by nurses or in hospitals. It would be very difficult to change packaging where the packaging also had to meet the EC and other regulations (e.g. information printed in multiple languages). As an alternative to printing instructions on the packs, books/leaflets and flow charts could be developed.

Post trial interviewPost trial interviewClear need to research mentor visits to keep things on track & explain project

Style of project involved whole teamWound care stock tends to be bought not sold!Being in project was good PR for pharmacies (since perception of cutting edge & involved in research)Most would do projects like this again if interested in topic & time pressures

Wound care stock being bought not sold was felt to be a core problem, where wound care was mostly customer self-selection. But part this selection was also affected by poor consumer knowledge of modern wound care. Self selection needed to be improved but Harry Gibbs that you don’t want total self-selection if the selection is going to be wrong. Part of the problem is that pharmacies are busy and customers don’t want to wait – since information is not ready, customers are not referred on when needed.

Again this is an issue of process versus content – there needs to be triggers for referring on, so that customers know that they need assistance, or that assistants know to consult the

E - 9

pharmacist etc. Pharmacists recognised market positioning from a wound care focus, but the panel felt that if pharmacists wanted a role in the home health care of wounds, they would need to be prepared to make an effort. The question is, are pharmacies wanting simple education more than selling very little wound care? Is quality only represented in large pharmacies with several wound care-educated staff?

Discussion issues&

Recommendations

Discussion issues&

Recommendations

Tasks still to doTasks still to doMore analysisAdd context to flow diagram as “best practice” & define activities

Quality wound care is multi-disciplinaryTake history & assessments for the purpose product of using product – not diagnosisLots of referral points

What is a minimum standard?Most pharmacies not aiming at best practice levelAim of service to ensure the appropriate use of an appropriate product to get the best outcome ??? Concentrate of first part of flow diagram initially




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant




No


Yes


Seeksconfirmation

of choice


product selected

No

Yes


assistant


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist


this wound


No

Satisfactorywound

progress

No

Refer topharm-acist


Refer topharm-acist


<=4wks



Yes

Refer topharm-acist

Yes

Treatmentso far

No



Unc

erta

in

Known,Chronic

Known, acute

High risk


Effe

ctiv

e



Refer topharm-acist

Yes

The flow chart developed as part of the project could be sliced up to meet the needs of consumers and assistants etc.

Wound care service is about…Wound care service is about…Methodical, systematic approachKnowing resourcesKeeping an appropriate stock rangeKnowing abilities AND limitations

When to referPharmacy assistants to pharmacistPharmacist to medical services

Start keeping recordsOngoing involvement after referral

Geoff Sussman said that modern wound management was about holding less stock, but more appropriate stock. Record keeping is important – as John Chapman said “If you didn’t write it down, it didn’t happen”. The lack of records would preclude assessment of wound care outcomes.

E - 10

Where to next Possible Recommendations

Where to next Possible Recommendations

Need for tools to move towards better practice

Simple tools for product selection (non-company based)Protocol for referral & networking for local healthcare providers

Appropriate education for assistants delivered in appropriate manner

Geoff Sussman indicated that product selection tools were in development. Protocols still need to be developed, but pharmacies need to identify the limit of their resources to know when to refer to get best patient outcome. Kathy Kendall felt that part of the protocol should also appear at the wound care display to help customers know when to seek advice. Geoff Sussman indicated that he would be providing a national referral list (to wound experts)

A recommendation should be that careful and independent (of manufacturers) “treatment” tools should be developed. Kathy Kendall suggested that there was a potential need to recognize cognitive input into wound care through, for example, the PBS etc, since good wound care was about preventing future costs and was risk sharing with the government. Tanya Parisi indicated that most companies offered training courses (e.g. the Woundwise course) but the courses were not offered to all because of the cost.

Appropriate product packagingAppropriate product packagingPack size too large – need pharmacy packs (1-3 units/pack). Packs should also have basic instructions for use on each dressing unit. This benefits self-selection by the customer who otherwise may not get this information. The ability to self-select dressing very important by consumers (per consumers) Pharmacies behaviour indicates they also rely on self-selection

In addition to getting the smaller pack sizes, Michelle Bou-Samra said that some specialty dressings were not kept by wholesalers because the volume was too low, as the perceived demand at the pharmacy level was low. There needed to be a specialty niche wholesaler and pharmacies needed to be able to feedback to wholesalers when they had a request because of being out of stock or stock unavailable.

Pharmacies need to ‘sell’ dressings and help the consumer recognize when they need to move from self-selection to seeking advice. This is partly a confidence issue related to expertise and knowledge but also involves change customer and staff mind sets about old dressings with a cheaper purchase price. The panel agreed that there was a need for information for consumers to know what they were using and the relative costs (including total costs) but that this was really part of the merchandising issue. Mike Roberts said that, based on the pilot and panel discussions, there was a need to develop a system for basic wound care. This system should include outcome assessments i.e. of wound healing.

Address merchandisingAddress merchandisingNeed to optimise shelf space (or novel storage arrangement) and presentation (order by functionality??). Need simple visual aids to help customers select the best product or give non-brand specific choices for treatment

A lot of the merchandising issues may fall to manufacturers but there are pressures on pharmacies to buy certain quantities or a range of products (often better deals). Geoff Sussman pointed out that pharmacies don’t need a large stock to provide effective wound care, rather less but more appropriate stock. Harry Gibbs had concerns about direct marketing of wound care to consumers, since consumers can either lose money from using the wrong, but very expensive dressings or

E - 11

make matters worse, for example, using an occlusive dressing on an infected wound. Merchandising should include visual aids to add to the wound care process. This would help build pharmacy assistant confidence, letting them focus on the issue and overcome the fear of liability that may contribute to lack of product recommendation.

Require 2 tiers of indicatorsRequire 2 tiers of indicatorsBasic wound care

a supply function and needs to focus initially on stock range, merchandising for self-selection and basic staff knowledge of appropriate product use

Wound care as a specialty practice. focus on service delivery (stock range & staff knowledge better addressed) incl. staff interventions e.g. assistance selection & best use of dressings, customer follow-up of wound healingappropriate merchandising for self-selection (since customers will still self-select, especially if the pharmacy is busy)

Based on the pilot sites, Julie suggested that there may be two tiers of service level for wound care but Geoff Sussman felt that there should be 3 tiers, basic, intermediate and advanced. The panel felt that more work (and extra funding) was required to establish standards and the break points between tiers. The panel members agreed that they would be happy to participate in a project to develop standards.

Effectiveness as self-auditEffectiveness as self-auditAs a pharmacy self-audit package, the data collection tools are feasibleSome indicators can be deleted but others appropriateSome changes may be required for p’cieswhere wound care is a specialty practiceMay need a bigger body of independent quality assessments since self-reported quality > audit rating

Julie indicated that more numbers would be required to do regressions of indicators that adjusted to covariates. Harry Gibbs asked whether there might be additional indicators of quality that had not been measured. As a benchmarking set of information, more sites would need to be added for whom the independent quality measures were calculated and if the mystery shopper were visits were to be redone, the scoring system may need to be redone to consider the quality of any

advice given. The self-audit kit would also need to include the methodology to aggregate any variables, to enable comparison to the benchmarking set. Indicators are needed for staff training. Since quality is not uni-dimensional, it is likely that a number of quality indicators will be needed. One of these is outcome data, but this type of data is going to be difficult to obtain unless there is a change in attitude towards data collection in community pharmacy.

Critical success factors for research in community pharmacy

Critical success factors for research in community pharmacy

Should be recognised and supported by pharmacy organisationsResearch projects conducted in community pharmacies should address the critical success factors such as mentoring and this should be allowed and expected as part of the costing of these projectsPharmacies need to be acclimatised to data gathering

The panel felt that the “pull” from the consumer should also be included as a critical success factor for research in pharmacy. Pharmacy needs to build capacity for changing trends, and in wound care, this means using assistants better and upskilling pharmacists and staff to handle the more pharmacologically advanced wound treatments that will be on the market in the next 5-10 years.

Funding for the development of assistant wound care protocols should be sought, for example, from the funding related to diabetes, and this could be part of the ‘pull’ from consumers such as those in the Diabetes Association. The panel felt that programs needed to be put in place to address the lack of confidence and the lack of willingness of pharmacy staff to interact with wound care customers to provide a quality service. The development and provision of simple aids to product selection would be

E - 12

part of the program. The current study was useful in that it meant that wound care got the attention of the pharmacist but what they needed was the time to focus on the area and then to look at implementing changes to improve. The current study is a model for quality management but many prospects fail in the implementation of change phase and need ‘hand-holding’ from mentors. The model of benchmarking and indicator development could increase attention and focus for different pharmacy areas e.g. child health. The panel considered the methodology of the study to be an effective process for indicator development that could be translated to other areas of pharmacy practice if the expert panel membership reflected stakeholders and experts in the specific areas targeted.

F - 1

APPENDIX F – FEEDBACK REPORT TO PHARMACIES

REPORT TO PHARMACIES FROM THE STUDY:

Wound care benchmarking in community pharmacy – piloting a method of QA indicator development1

Table of Contents INTRODUCTION ....................................................................................................................... 1 1. BENCHMARK DATA ........................................................................................................ 2

1.1 AUDIT VISIT.................................................................................................................. 2 1.1.1 Layout of wound care section............................................................................ 2 1.1.2 Perceived quality measures............................................................................... 4

1.2 PROFILE COMPLETED BY THE PHARMACIES .................................................................... 5 1.2.1 Pharmacy characteristics and workload ............................................................ 5 1.2.2 Proprietor/Manager perceptions of service and quality ..................................... 6 1.2.3 Stock selection and turnover ............................................................................. 8 1.2.4 Human and information resources .................................................................... 9 1.2.5 Policies and procedures maintained.................................................................. 9

1.3 STAFF QUIZZES ......................................................................................................... 10 1.4 STOCK ON HAND REPORTED BY PHARMACIES............................................................... 12

1.4.1 Stock holdings versus turnover from wound care ........................................... 14 1.5 SALES/PURCHASE DATA.............................................................................................. 14 1.6 CUSTOMER TELEPHONE SURVEY................................................................................. 15 1.7 CUSTOMER LOG ......................................................................................................... 16

1.7.1 Appropriateness of products provided............................................................. 18 1.7.2 Comparing wound types seen in 2 weeks with estimates ............................... 18

2. INDEPENDENT QUALITY MEASURES......................................................................... 23 2.1 MYSTERY SHOPPER VISITS ......................................................................................... 23

2.1.1 Mystery shopper scores................................................................................... 23 2.2 INDEPENDENT QUALITY SCORES.................................................................................. 24

3. INDICATORS VERSUS INDEPENDENT QUALITY MEASURES ................................. 25 3.1 PHARMACY CHARACTERISTICS .................................................................................... 25 3.2 LAYOUT OF WOUND CARE SECTION.............................................................................. 25 3.3 PHARMACY CHARACTERISTICS AND WORKLOAD ........................................................... 26

3.3.1 Proprietor/Manager perceptions of service and quality ................................... 27 3.3.2 Stock and sales ............................................................................................... 28 3.3.3 Human and information resources .................................................................. 28 3.3.4 Policies and procedures maintained................................................................ 28

3.4 QUIZZES.................................................................................................................... 28 3.5 CUSTOMER LOG ......................................................................................................... 29

CONCLUSION......................................................................................................................... 29

1 This project was funded by the Commonwealth Department of Health and Ageing as part of the Third Community Pharmacy Agreement through the Third Community Pharmacy Agreement Research and Development Grants (CPA R&D Grants) Program managed by the Pharmacy Guild of Australia

1

INTRODUCTION The data collection and analysis phase of this study has been completed. As was described when your pharmacy enrolled in this study, this report has been prepared for your information regarding the outcomes for your particular pharmacy and an anonymous comparison with other pharmacies in the study. A letter accompanying this report will identify the code for your pharmacy but will not identify any other pharmacy or location. Acting on the outcomes of the report constitutes a CQI activity as defined in the QCP Program. Even without this benefit, the investigators hope that the information will be at least informative about their own and other wound care practices and services. A benchmarking process was used so that each site would be able to compare itself to the others and the benchmark (the leading site). Consequently, results are presented per site as well as in an overall form. The benchmark site in this study was M01, although M03 and M04 were also identified as having more advanced wound care practice. Only relevant and statistically significant outcomes for services and practice have been included in this report (out of the large amounts of data collected). This report has been tailored to make the outcomes identifiable and actionable in each pharmacy setting. The features of this report are: • The benchmarking data. This section describes each potential indicator showing how

various sites fared. In this section, proprietors will be able to compare the results from their pharmacy with those from other pharmacies, including the benchmark site. This section has the correct answers to the quizzes that pharmacists and assistants completed.

• Independent quality measures - a variety of independent measures (i.e. measures or assessments conducted by independent assessors who not involved with or employed by any individual pharmacy) that allows for comparison between sites as well as general measures of service quality

• A comparison of the potential indicators and the independent quality measures – this assesses the relationships between indicators and independent quality measures

Interpretation of indicators of quality. We have summarised those indicators that were and were not related to the independent quality measures. Indicators associated with better service quality might point to areas for improvement in individual pharmacies, but note that the results do not mean that the indicator ‘caused’ better quality. For example, merely changing a sign from “first aid” to “wound care” will not improve service quality. It is more likely that the choice of signage reflects an underlying commitment to wound care by pharmacy proprietors/managers who choose to sign the area as “wound care” rather than “first aid”. Key messages. 1. In addition to the benchmarking details provided, the study highlighted that

proprietor/manager impressions about the wound care service provided poorly reflect the actual situation as shown, for example, by the customer log. For pharmacies to carry out effective audits in any practice area, objective data must be compiled.

2. Pharmacy assistants are critical in the provision of a quality wound care service. Strategies to improve the service must therefore be team based, including both pharmacists and assistants in the process.

Now on to the details….

2

1. BENCHMARK DATA 1.1 AUDIT VISIT The data collected at the audit visit was largely observational. Data were recorded about the wound care section layout including location of the wound care section relative to other areas of the pharmacy, the nature of the display and the stock holdings. A global assessment of quality was also made.


Finding the location of the wound care section was not always easy - 42.9% of pharmacies had no sign indicating where wound care or first aid products were located (3 of the 5 site were QCPP accredited per the wound care profile) although at one site, the display was very visible. Four sites (28.6%) had signs indicating “First Aid” and the sign at 4 other sites said “Wound Care”. The average amount of pharmacy shelf space dedicated to wound care or first aid was 9.7 linear metres (median 8.1 metres, range 3.6-21.0). The average amount of space for first aid products was 4.7 metres (median 2.9 metres, range 1.2-16.0), and for wound care products 5.0m (median 3.6 metres, range 1.8-15.0). The proportion of total space set aside for wound care products was, on average, 54.8% (range 57.4 range 15.4-87.5). Again, both the total shelf space and the proportions for wound care versus first aid varied across the sites (Figure 1.1).

0

20

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M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

% o

f tot

al d

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)Wound Care%

First Aid%


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M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

% o

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5

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Tota

l dre

ssin

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)Wound Care%

First Aid%


Figure 1.1 Linear metres of shelf space for wound care and first aid products and

the percentage occupied by each product type

All but 2 sites (M01 and R08) used manufacturers’ displays/shelving aids – 2 sites used a lot of these displays while the remaining 10 used some manufacturers’ displays. Sites with the smallest amount of total dressing shelving used a lot of manufacturers’ displays while sites that had no manufacturers’ displays had more wound care shelving.

3

Table 1.1 Median amount and percentage of dressings shelf space compare by pharmacy size and rural and metropolitan location

Pharmacy size Location <200 m2 >200 m2

Overall size

Median N Median N Metropolitan 1.80 3 2.90 4 2.15 Rural area 2.10 2 9.00 5 7.00

Shelf space for first aid dressings Overall 1.80 3.00


Shelf space for wound care dressings Overall 3.35 5.00


Total dressings shelf space

5.40 10.00 Metropolitan 60.91 3 77.67 4 65.11 Rural area 65.15 2 30.00 5 44.44

% of total dressing shelf for wound dressings Overall 63.64 50.00

At audit, only one site, the benchmark site, displayed easily visible information for wound care product selection; the pharmacy personnel had developed this information themselves. At a post-trial interview visit, another site (R02) drew the researchers’ attention to a product selection poster a little to one side of the wound care section which had been overlooked at audit. Since wound care products are odd shapes and at time difficult to display, the neatness and arrangement of wound care stock was assessed. The first aspect considered was whether the wound care products were all together – 2 sites (14%) managed this well (the benchmark site and M03), 9 sites (64%) were mostly able to arrange wound care products together while 3 sites did not really have the wound care products together (e.g. they were interspersed with tapes, bandages and first aid). The second aspect was whether the different products could be distinguished by looking at the display. No site was able to successful display all products, but half of the sites were mostly able to achieve this (M01, M03, M04, R01, R02, R05, R06). For the remainder, some products had to be pulled out to see what they were. The third aspect was whether there were part packs of old-looking stock (e.g. that might be leftovers from a particular order and did not look like part of the usual range) – all sites had stock like this. In terms of the stock ranges carried, all sites carried multiple brands of passive dressings and first aid products in multiple sizes, with all but one carrying more than 10 units. All sites carried at least one brand of film and hydrocolloid dressings although not all sites carried more than one size of these dressings. For hydrogels, half of the sites carried more than one brand but the majority kept only a small number of units of stock. Ten sites did not carry cadexomer iodine or hydrofibre dressings and just over half of the sites carried any zinc paste bandages. These latter 3 dressings also had the lowest mean stock range scores and the lowest overall stock level scores 2. Next to passive dressings and first aid, films had the

2 . For each site, a “stock range” score was calculated. For each dressing type category, the number of bands stocked (where none=1, one brand=2, more than one brand=3) was multiplied by the number of sizes stocked (none=0, 1 size=1 and more than 1 size = 2) giving a score for each dressing type of between 0-6. The scores for all dressing types were summed to give a stock range score. A total stock score was also calculated by multiplying the stock range score for each dressing type by the number of individual units stocked category (where 1=<5 units, 2=5-10 units and 3=>10 units). Again, the scores were summed for each dressing type.

4

highest stock level and stock range scores. Foams, hydrocolloid, hydrogel, polymer and alginate dressings had intermediate scores. Sites M01 and M04 had stock in each category, and the benchmark site (M01) carried more hydrocolloid dressings. M08 had the narrowest stock range (only keeping stock in 5 out of 11 categories) followed by M05. Once the 3 high level metropolitan pharmacies are excluded (M01-M04), there is a tendency for rural pharmacies to have a broader stock range and to have greater stock levels overall with no relationship between pharmacy size (greater or less than 200m2) and stock range or stock level.

1.1.2 PERCEIVED QUALITY MEASURES

Based on the findings at the audit visit, the auditor made quality assessments on 4 dimensions, each with a score out of 100 (a visual analogue scale): • Overall level of quality of wound care service (poor to excellent) • The wound care service level provided (rudimentary (basic first aid only) to advanced (e.g.

treat complex chronic wounds) • The extent to which space and facilities met the needs of wound care service level

provided (not at all to completely) • Whether the wound care display was organised to aid customer self-selection of dressings

(does not assist to fully assists) When the ratings scores were summed, M11 had the lowest total score followed by R04 and R06. Site M01 was rated most highly, followed by M03, M04, R02 and R05. The overall quality rating and the service level score were very similar for all but 2 sites (R06 and R08) (Figure 1.2 A), but the space and facilities needs and display for self-selection ratings varied more from the overall quality rating (Figure 1.2 B). These quality ratings were related to each other; as one increased, the others also increased, so that the auditor was generally consistent for each pharmacy for all 4 ratings.

5

0

10

20

30

40

50

60

70

80

90

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M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Aud

it R

atin

g sc

ore


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10

20

30

40

50

60

70

80

90

100

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Aud

it R

atin

g sc

ore


B

Figure 1.2 Perceived quality ratings at audit (A) overall and service level; (B) overall,

space and facilities needs, and display for self-selection

1.2 PROFILE COMPLETED BY THE PHARMACIES

1.2.1 PHARMACY CHARACTERISTICS AND WORKLOAD

Participating pharmacy sites had, on average, 1.8 effective full-time equivalent (EFT) pharmacists (median 2, range 1-3) and 4.8 EFT pharmacy assistants (front of shop and dispensary) (median 4, range 1-12). The amount of time there was more than one pharmacist present per week in each pharmacy is represented in Figure 1.3.

6


5550454035302520151050-5

No.

EFT

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

.5

R08

R06

R05R04

R02

R01

M11

M08

M06

M05M04

M03

M01


5550454035302520151050-5

No.

EFT

pha

rmac

ists

3.5

3.0

2.5

2.0

1.5

1.0

.5

R08

R06

R05R04

R02

R01

M11

M08

M06

M05M04

M03

M01


5550454035302520151050-5

Trad

ing

hour

s/w

eek

120

110

100

90

80

70

60

50

40

R08R06

R05

R04R02

R01

M11M08M06

M05

M04M03

M01


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ing

hour

s/w

eek

120

110

100

90

80

70

60

50

40

R08R06

R05

R04R02

R01

M11M08M06

M05

M04M03

M01

Figure 1.3 Number of hours/week when there was more than one pharmacist on

duty versus number of EFT pharmacists and trading hours/week

Ten of the 13 responding pharmacies were accredited with QCPP. Of those that were not accredited, one had completed more than 50% of the required work whilst the remaining two had achieved less than 50%. Community pharmacies extend services into residential aged facilities and community nursing organizations. Of the sites completing the profile, 46% (M01, M04, M08, R01, R02, R04) indicated that the pharmacy supplied wound care products to residential aged facilities and 18.2% (M01 and M04) supplied wound care products to community nursing organizations.

1.2.2 PROPRIETOR/MANAGER PERCEPTIONS OF SERVICE AND QUALITY

Proprietors or managers were asked to make the same 4 quality assessments as the auditor for: • Overall level of quality of wound care service • The wound care service level provided • The extent to which space & facilities met the needs of wound care service level provided • Whether the wound care display is organised to aid customer self-selection of dressings The majority of pharmacies believed that their wound care service quality was more than halfway to being excellent, that space and facility needs were met, and that wound care was displayed to aid customer self-selection. Generally, proprietors/managers rated the overall quality of the service they provided as equal to or higher that the service level (ranging from rudimentary to advanced), except for one site where the service level provided was rated considerably higher than overall service quality (Figure 1.4). Compared to the auditor ratings, the various ratings made by each proprietor/manager were not as consistent with each other since only 2 of the 6 potential correlations between these ratings being significant. When the service level provided was rated more highly, so too was the overall quality level, however, the extent to which space and facility needs were met declined. The actual shelf space variables (from the audit) did not correlate with the proprietor’s rating of space and facility needs. Only the amount of shelf space for wound was related to any proprietor quality assessment, overall quality. Comparing Figure 1.4 with Figure 1.2 will indicate where the proprietor and auditor ratings deviated.

7

0

10

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M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Prof

ile R

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ore


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M01 M03 M04 M05 M06 M08 M11 R01 R02 R04 R05 R06 R07 R08

Prof

ile R

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ore


B

Figure 1.4 Perceived quality ratings per profile (A) overall and service level; (B)

overall, space and facilities needs, and display for self-selection Eight of 13 pharmacies had written information about wound care available for the customer to take away. Typically most (5) offered manufacturers pamphlets while the remaining 3 (M06, R02, R04) used computer printouts as their consumer information source. Pharmacists were asked to look back over a 2-week period and comment on any wound care transaction: 92.3% of pharmacies said that assistants sought the pharmacist’s input on at least one occasion; only 38.5% of pharmacies sought detailed histories whilst just 7.7% kept written records of consultations. In this period, 90.9% of the pilot pharmacies believed that customers had been persuaded to purchase a more appropriate dressing. Actual rates for influencing customer choice from the log are shown in Table 1.11. Proprietors were also asked about referral patterns. On average, pharmacies had referred 4.25 customers (median 4, range 0-10) to other health professionals in the last 4 weeks. Three of the pharmacies had referred 10 patients (M01, M04 and R04) and one reported (M03) referring 20% of wound care customers to other health professionals over the 4-week period. M05, R01 and R08 said no customers had been referred on in the last 4 weeks. R05, R06 and M08 indicated that 5 customers had been referred while M06 and R02 referred 2 and 3

8

customers respectively. These referral patterns did not match the log (Table 1.11) with 5 of 12 sites overestimating their actual referral rate and 3 site underestimating referrals. Of the 12 responding pharmacies, half reported (M01, M04, M06, M11, R04, R06) that they had customers referred to them by other health professionals for wound care services in the previous 3 months.

1.2.3 STOCK SELECTION AND TURNOVER

Proprietors were asked how they selected the range of products stocked. Primary factors affecting the range of products stocked in pharmacies are categorized into four groups: • Recommendation by other health professionals (e.g. nurses, doctor, or community nursing

services) in 4 pharmacies • Advice by company representatives and manufacturers (includes supply of quality range

of products) in 5 pharmacies • Education (wound care seminars, lectures) in 2 pharmacies • Requests for specific dressings (direct requests, customer needs) in 2 pharmacies Some of the secondary factors influencing whether products were stocked were sales history and sales data, availability or level of company support, products that pharmacies are most experienced with using, banner group planograms and product costs. Eleven of 13 responding pharmacies stated that they did review their wound care product range. The primary criteria used in this review were: • Previous sales figures (8 sites) or customer demand/requests (3 sites) • Advice from company representatives (4 sites) • Pharmacy magazines, lectures and wound management leaflets (2 sites) • Product prices and prices of competitors Based on the reviews over the last 12 months all 12 responding pharmacies reported making changes to the stock range they carried. Turnover: Eleven of the 14 pharmacies indicated what proportion of pharmacy turnover was related to wound care products. Wound care was less than 1% of turnover for M05, M08, M11, R05 and R06 and between 1 and 2% for M06, R01 and R08. Pharmacies M01 (>5%), M03 (4-5%) and M04 (2-3%) reported that wound care products contributed to greater than 2% of their annual turn over last financial year. Generally, the percentage of turnover from wound care products increased as the following increased: • The linear metres of shelving for all dressings • The linear metres of wound care shelving • The percentage of total dressing shelves for wound care • The trading hours/week • The proprietor’s perception of the overall service quality provided by the pharmacy • The proprietor’s perception of the service levels (rudimentary to advanced) provided by

the pharmacy • The proportion of products sold in the 2 weeks of the log that were not passive, first aid or

other dressing products i.e. the more advanced dressings sold, the greater the proportion of turnover from wound care.

• Stock holdings (see 1.4.1)

9


Ten of 12 pharmacies had wound care trained pharmacy assistants as reported by proprietors/managers. The median number of trained staff was 2 (range 0-5). Only 2 sites had more than 3 pharmacy assistants with wound care training. Proprietors reported that the majority of the trained assistants were training within the last 2 years. These numbers did not always agree with the training reported by pharmacy assistants in the quiz (1.3). The proportion of the pharmacy trading hours that wound care trained assistants were on duty varied. Overall, there was at least one wound care trained assistant on duty for a median of 50% of the trading hours (range 0-100%). Only 3 out of 9 pharmacies had at least one trained wound care pharmacy assistant on duty for the entire trading time. The benchmark site (M01) had a trained assistant on duty 75% of the trading hours but this pharmacy had the longest trading hours (112 hours). Generally, the percentage of trading hours covered by a wound care trained assistant increased as the number of trained assistants increased. Proprietors’ beliefs about service quality were related to the proprietors reports of the number of pharmacy assistant with wound care training but were not related to pharmacist training. The proprietor’s perception of the overall service quality provided by the pharmacy increased as the number of pharmacy assistants with wound care training and the percentage of opening hours were a wound care trained assistant was on duty increased. Of the 12 sites responding to the question on pharmacist training, there were 4 sites at which no pharmacists had received wound care professional development in the last 2 years. Those that had received training listed training activities as: • PSA or other lectures (typically by Geoff Sussman or Jan Rice) – sometimes more than a

single lecture e.g. wound care course or lecture series (5 sites) • Wound care as part of the university pharmacy course (1 site) • PAC wound care workshop (1 site) Only 1 of 13 pharmacies had another specialist staff member providing wound care services. However, 10 of 13 pharmacies knew of other health care providers in their area, which they could refer customers to for more complex wound care but only 1 of 11 had this information documented (M01).

1.2.5 POLICIES AND PROCEDURES MAINTAINED

None of the 13 pharmacies documented any information collected in discussion with customers about wound care, nor did any site have any other documents or standard forms to support their wound care service (either wound care referral forms, records of the wound care treatment recommended or provided, or records of wound monitoring and review of wound healing). Four of the 11 responding pharmacies (M01, M06, M08, R01) kept patient wound care records, but did not record the outcome of that care. The remaining sites did not keep patient wound care records. Few sites reported having written policies or procedures. The majority of pharmacies had policies or procedures related to the supply (stock levels) and appropriate use of a product, although these tended to be unwritten. Only 2 had procedures for monitoring wound progress, albeit unwritten. Only 5 sites had policies or procedures (mostly unwritten) related to staff and pharmacist training or maintenance of current knowledge or skills. The majority of sites had policies on referral but fewer had policies or procedures on just how to make a referral.

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1.3 STAFF QUIZZES Quizzes were returned by 20 pharmacists and 33 pharmacy assistants across 11 sites. There were 18 questions that were asked of both pharmacists and pharmacy assistants, and 6 short answer questions asked of the pharmacists. The pharmacy assistant quiz also sought inform-ation about the extent to which the assistants persuaded customers to purchase a more appropriate product, whether the assistant had had any wound care training and the assistants’ estimates of the types of wounds seen. The overall percentages of incorrect responses are shown in Table 1.2 and Table 1.3. Pharmacists generally did well with appropriate referral, although most would expect staff to refer a small sore of 1 weeks duration to the pharmacist (as did staff) but 15% would not have expected a moderately large burn on a child to be referred to them by pharmacy assistants. A concern is that almost 10% of pharmacy assistants would not refer a chronic leg ulcer to a pharmacist, but continue to supply Melolin (perhaps related to the mystery shopper experience, 2.1). Pharmacy assistants beliefs about wound healing (i.e. a scab is good) may be behind this lack of referral.

Table 1.2 Percentage of incorrect responses to quiz questions answered by both pharmacy assistants and pharmacists

% incorrect responses Questions on situations for automatic referral to pharmacist/seek other help, or answer true or false

Correct answer Assistant Pharmacist


No 66.7 60.0

A graze on the knee that is bleeding a little after coming off a skateboard No 3.0 5.0 A lady who comes in weekly for the last several months for more Melolin for her ulcer

Yes 9.1 5.0

A child with a very painful red burn, & a small blister after being scalded by hot water spilled from a kettle – area is about 6cm x 6cm on the arm

Yes 6.1 15.0

A middle aged man with a sore on his toes that he says is painless but looks a bit yellowish and black. He is also getting his prescription for his diabetes tablets

Yes 0.0 0.0

A woman with a wound on her leg – she doesn’t know how it started – but it is quite painful and very red around it. She says it feels hot to touch

Yes 0.0 5.0

Lyofoam is a foam dressing True 3.0 5.0 Film dressings, eg Opsite or Tegaderm, are good for bleeding wounds False 27.3 5.0 Duoderm can be used on any wound False 12.1 25.0 A scab is good as it protects the wound False 66.7 15.0 Moist wounds heal faster than dry ones True 3.0 10.0 Applying local pressure can help stop minor bleeding True 0.0 0.0 Dressings with charcoal in them are for smelly wounds True 21.2 30.0 Dressings should always be changed at least once each day False 21.2 0.0 You should never use Betadine on any wound False 6.1 5.0 Hydrogels dressings (eg Intrasite or Solugel) are only good for wounds with a lot of fluid or exudate coming out of them

False 6.1 10.0

Solugel can be used on chicken pox and minor burns True 6.1 0.0 Gauze is a good dressing to use on any wound False 12.1 0.0 When asked short answer questions that required more detailed wound care knowledge, pharmacists indicated some product knowledge of the advanced dressing types but performed least well in questions related to more unusual dressings (Aquacel and zinc paste bandages) (Table 1.3). Pharmacists recognised factors for referring a patient to their GP, although only one identified all 4 risk factors, and one quarter of pharmacists identified more than 2 factors. Some pharmacists did seek to help answer these questions, mostly in relation to the questions about Aquacel (10 sites did not stock Aquacel) and zinc paste bandages. The resources used were APP Guide or MIMS (3), lecture notes/materials from the Wound Foundation or other lecturers (Jan Rice) (3), APF (1), a nurse on staff (1) and the manufacturer (1 – although a response was not received in time).

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Table 1.3 Percentage of incorrect responses to short answer quiz questions answered by pharmacists

Questions requiring a short answer Correct Answer % incorrect Diabetic 15.0 Not improving 45.0 Painful 80.0

A regular customer of your pharmacy is collecting his prescription for his gliclazide and asks for some Melolin® for a sore on his shin. On inquiry, he tells you that it has been there for about two weeks after he scratched it in the garden and doesn’t seem to be getting any better. It is still painful. He says it is about the size of a 10 cent piece and his dressing gets so wet he needs to change it at least twice a day. What would be the key factors you would consider that would indicate the need for you to refer him to his GP?

Potential for infection due to nature of injury

55.0

Calcium alginates only (1 mark) 75.0 Do sodium or calcium alginates act as a haemostatic agent? Please name one brand of this type that acts as a haemostatic agent

eg Kaltostat (1 mark) 25.0

It only absorbs exudate vertically from the wound (1 mark)

60.0 The vertical wicking properties of Aquacel mean what?

Protects the skin surrounding the wound from maceration (1 mark)

85.0

Apply principle of moist wound healing & stop scab formation (1 mark)

15.0 What makes a hydrogel a useful treatment for chickenpox?

Keeps nerve endings moist to reduce irritation (1mark)

55.0

Amount of exudate (1 mark) 35.0 What feature of a wound would influence your choice of a foam dressing instead of a hydrocolloid? Foam is more absorbent than

hydrocolloid (1 mark) 85.0

Red, superficial wound (1 mark) 95.0 What are the simple indications for using a zinc paste bandage? Wound with surrounding venous

eczema or irritation (1 mark) 90.0

Generally, pharmacists and pharmacy assistants did well in correctly responding to these questions with overall mean scores being between 15 and 16 out of 18 (Table 1.4). Pharmacists did less well for question 3 (short answers) with an average score of 6.2 out of 14 (range 2 to 12).

Table 1.4 Quiz results for pharmacist and pharmacy assistant quizzes

Pharmacist quiz Pharmacy Assistant quiz

Site

No. pharmacist responses

Mean score for

Q1+2 Mean

score Q3

Mean % total score (Q1+2+3)

No. assistant responses

Mean score for

Q1+2

Mean % of customer persuaded

No. PAs with wound

training M01 4 15.75 6.00 67.97 1 12.00 - 0 M03 2 17.00 9.00 81.25 7 15.00 65.00 1 M04 3 17.00 7.33 76.04 3 16.33 26.00 1 M05 2 14.50 5.00 60.94 2 14.50 80.00 2 M06 1 15.00 7.00 68.75 1 17.00 60.00 1 M08 1 16.00 3.00 59.38 2 14.00 3.50 0 M11 1 13.00 4.00 53.13 1 9.00 - 0 R01 2 15.50 6.00 67.19 4 15.00 56.25 3 R02 2 17.50 8.00 79.69 3 17.00 70.00 3 R04 - - - - 3 16.00 - 0 R08 2 16.00 4.00 62.50 6 16.50 46.00 1 Overall Mean 15.95 6.20 69.22 15.36 52.25

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Pharmacy assistants were also asked about the percentage of wound care customers they had been able to persuade to purchase a more appropriate dressing than the one the customer had initially requested or selected. Overall, pharmacy assistants estimated they had influenced about half of the wound care customers to make a more appropriate purchase (Table 1.4), however, one site reported persuasion with 80% of wound care customers while assistants at some sites rated their persuasive powers as low (less than 30%). The figure from the customer log for the average percentage of customers influenced in their purchase was 61%. Pharmacy assistants at 4 of 8 sites underestimated their influence compared to that reported in Table 1.11. Twelve of the 33 responding pharmacy assistants reported having received any wound care training (Table 1.4). Some of the training was recent and some a long time ago: • Wound Wise training in the last year (2) • Other training from companies (3) • A Wound management course (including the Victorian College of Pharmacy course) (3) • First Aid Certificate (3) • Pharmacy Guild of Australia product knowledge booklet on “Wound Care” read about 12

months ago (1) • Other, unspecified wound training (a long time ago) (1) Pharmacy assistants with wound care training had significantly higher scores for the quiz than those without and were more likely to report influencing customer choices of dressing products. From the small number of pharmacists whose training status could be determined from the profile, training had no effect on quiz performance.

1.4 STOCK ON HAND REPORTED BY PHARMACIES The quality of the data recording of stock on hand was varied, making detailed comparisons difficult. In many cases the number of single dressings was not specified or only estimated (particularly for passive and first aid dressings). The most commonly stocked category of dressings was the passive dressings, followed by film and hydrocolloid dressings. The single most common products stocked were Melolin (10 reported but probably 11 of 12 sites), Lyofoam and Solugel (10 of 12 sites each). The Duoderm range included Duoderm, Duoderm extra thin, CGF and paste but 10 sites carried at least 1 Duoderm product. Kaltostat included sheets and ropes of dressing and was stocked by 9 sites. Bandaid strips were the most commonly stocked line of simple first aid products. The number of different dressing types carried in each dressing category at each site is shown in Table 1.5. The most commonly stocked items overall were passive dressings followed by film dressings representing 25 and 14% of dressing products stocked, respectively. Excluding R04, whose stock report was incomplete, and the benchmarking site (M01), passive dressings represented between 17 and 43% of dressing products stocked. At the benchmark site, stock was kept across a range of categories.

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Table 1.5 Number of products stocked in each product category per site and percentage of total number of different products stocked

M01 M03 M04 M05 M06 M08 M11 R01 R02 R04* R06 R08 Overall Product category N % N % N % N % N % N % N % N % N % N % N % N % N %

Films 2 7.4 2 6.7 5 14.7 3 18.8 3 20.0 3 15.8 2 13.3 3 13.6 3 17.6 3 23.1 5 13.2 4 17.4 38 14.1 Foams 3 11.1 4 13.3 2 5.9 1 6.3 1 6.7 2 10.5 1 6.7 2 9.1 1 5.9 2 15.4 3 7.9 3 13.0 25 9.3 Hydrocolloids 4 14.8 2 6.7 5 14.7 1 6.3 1 6.7 2 10.5 2 13.3 2 9.1 2 11.8 3 23.1 3 7.9 0 0.0 27 10.0 Hydrogels 5 18.5 3 10.0 4 11.8 0 0.0 1 6.7 2 10.5 1 6.7 2 9.1 1 5.9 1 7.7 3 7.9 2 8.7 25 9.3 Polymers 3 11.1 2 6.7 3 8.8 0 0.0 0 0.0 0 0.0 1 6.7 3 13.6 2 11.8 1 7.7 3 7.9 0 0.0 18 6.7 Alginates 4 14.8 2 6.7 2 5.9 0 0.0 1 6.7 0 0.0 1 6.7 2 9.1 1 5.9 1 7.7 1 2.6 2 8.7 17 6.3 Hydrofibres 0 0.0 2 6.7 1 2.9 0 0.0 1 6.7 0 0.0 1 6.7 0 0.0 0 0.0 1 7.7 0 0.0 0 0.0 6 2.2 Cadexomer iodine 2 7.4 2 6.7 2 5.9 1 6.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 2.6 0 0.0 8 3.0 Zinc Paste Bandages 2 7.4 4 13.3 3 8.8 0 0.0 0 0.0 0 0.0 0 0.0 1 4.5 0 0.0 0 0.0 3 7.9 0 0.0 13 4.8 Passive dressings 2 7.4 6 20.0 6 17.6 7 43.8 5 33.3 7 36.8 4 26.7 4 18.2 4 23.5 1 7.7 13 34.2 9 39.1 68 25.3 First Aid 0 0.0 1 3.3 1 2.9 3 18.8 2 13.3 3 15.8 2 13.3 3 13.6 3 17.6 0 0.0 3 7.9 3 13.0 24 8.9 Total No. different products 27 30 34 16 15 19 15 22 17 13 38 23 269 N= No. product types in each category at each site and overall %= Percentage of total number of different products/site and overall * possible incomplete data for passive dressings and simple first aid Note: different sizes of the same product were not counted separately, rather different product types were counted e.g. Tegaderm and Tegaderm Island dressing were counted as two product types because they had different uses

14

Of more interest however, was the extent to which essentially equivalent products were stocked by the same site (antiseptic tulle gras (Bactigras) was considered to be essentially the same as tulle gras). Three sites had community nursing contracts which might account for the apparent stock duplication but the duplicated products carried by other sites tended to be passive dressings (16 duplicates/triplicates) and film dressings (13 duplicates/triplicates) (Table 1.6).

Table 1.6 Therapeutic duplication among the dressing types stocked

Dressing category Equivalent products stocked (irrespective of product size) Films Tegaderm - Opsite Hydrocolloid Comfeel Ulcer – Duoderm Extra thin; Comfeel Plus Ulcer - Duoderm

M01

Passive dressing Cutilin - Melolin Films Tegaderm - Opsite Hydrocolloid Duoderm - Replicare

M03

Passive dressing Jelonet - Bactigras Films Tegaderm – Opsite – Cutifilm; Cutifilm plus – Tegaderm Island Hydrocolloid Comfeel – Duoderm – Replicare - Curaderm

M04

Passive dressing Cutilin - Melolin M05 Passive dressing Jelonet - Bactigras

Films Tegaderm – Opsite flexifix – flexigrid shapes M06 Passive dressing Cutilin – Melolin; Cutiplast - Primapore

M08 Passive dressing Jelonet - Bactigras; Airstrip - Primapore M11 Passive dressing Jelonet - Bactigras

Films Tegaderm – Opsite – Cutifilm R01 Passive dressing Jelonet – Bactigras - Adaptic

R02 Films Nexcare Tegaderm – Opsite Post-op- Cleanseals Films Tegaderm - Opsite R04 Hydrocolloid Duoderm - Comfeel Films Tegaderm – Opsite – Cutifilm; Cutifilm plus – Opsite Post-op Hydrocolloid Comfeel – Duoderm – Replicare

R06

Passive dressing Adaptic - Jelonet – Bactigras - Unitulle; Airstrip – Primapore – Cutiplast - Hansapor; Cutilin – Melolin

Films Tegaderm – Opsite flexifix; Opsite post-op – Cutifilm plus Hydrocolloid Duoderm - Comfeel Hydrogels Solugel – Bandaid Healing gel

R08

Passive dressing Jelonet - Bactigras; Melolin – Cutilin – Telfa; Cutiplast - Primapore

1.4.1 STOCK HOLDINGS VERSUS TURNOVER FROM WOUND CARE

Higher stock levels as indicated at audit and in the current stock holding reported by pharmacies were generally associated with a higher percentage of turnover from wound care. As the stock scores for foam, polymers and zinc paste bandages, and the overall stock range and total stock scores increased, the percentage of turnover from wound care increased.

1.5 SALES/PURCHASE DATA Provision of sales/purchase data was limited by the lack of functionality of pharmacy POS systems for this audit purpose. Only six pharmacies provided sales or purchase history data. Two sites did not fill out the form by dressing category class. One of these sites sent in a POS printout while the other who could not compile sales data because of a change in the POS system, sent a purchase history report (possibly from their wholesaler). Four sites provided sales data from their POS, one site (mentioned above) provided purchase data while another site used a combination of sales and purchase data to compile the report.

15

Five of the six pharmacies had both usable stock data and sales/purchase history data. The percentage of simple first aid products sold or purchased ranged from 1.5% to over 60% (Table 1.7). In 3 of the 5 sites however, sales of passive dressings were the highest category. For 4 of the 5 sites, the percentage of sales made up by passive dressings exceeded the percentage of stock held that were passive dressings. R08 held more passive dressings than were sold, possibly related to the 9 different types of passive dressings stocked. For the majority of sites, the proportion of stock held for the more advanced dressing categories generally exceed the percentage of sales in these categories, although stock holdings and sales more closely matched for M04. Sites R01, R02 and to a lesser extent R08 has a good match between sales and stock for the hydrogels. Since only a small number of sites provided sales/purchases data, this could not be meaningfully compared to percentage turnover from wound care products but this information is in the last line of Table 1.7. As an alternative, sales as per the customer log were compared to turnover and are shown later.

Table 1.7 Average percentage of total wound care sales per quarter for each dressing category

Average % of total dressing units sold overall and excluding first aid products M01 M04 R01 R02 R08

Dressing category

Overall Exclude 1st aid Overall




Exclude 1st aid

Film 21.3 21.6 30.0 31.0 13.4 16.3 11.4 17.2 6.0 15.5 Foams 9.1 9.2 10.7 11.1 0.7 0.8 0.3 0.4 1.5 3.9 Hydrocolloids 5.0 5.1 10.1 10.4 1.1 1.3 1.3 2.2 1.8 4.6 Hydrogels 1.6 1.7 2.8 2.9 6.8 8.2 7.8 11.6 2.8 7.3 Polymers 1.1 1.2 8.8 9.0 1.9 2.2 1.3 1.8 0.0 0.0 Alginates 1.7 1.7 3.8 3.9 1.4 1.6 0.0 0.0 1.8 4.5 Hydrofibres 0.0 0.0 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0 Cadexomer iodine 2.5 2.5 2.7 2.7 0.0 0.0 0.0 0.0 0.0 0.0 Zinc paste bandage 2.6 2.7 3.4 3.5 1.0 1.2 0.3 0.4 0.0 0.0 Passive dressings 53.6 54.4 24.5 25.3 56.9 68.2 44.0 66.4 25.0 64.3 Simple 1st aid 1.5 3.0 17.0 33.7 61.3 % turnover >5% 2-3% 1-2% 1-2%

1.6 CUSTOMER TELEPHONE SURVEY Only 15 customers were recruited by 7 pharmacies, although 2 of these customers did not meet the eligibility criterion of having a current. Post pilot interviews indicated that pharmacies were selective in the customers they approached to recruit, rather than recruiting consecutive customers. This activity does not appear to be a useful indicator as implemented in the pilot study but certain aspects of the information derived from the few interviews obtained is informative. This includes:

• 89% of patients use that pharmacy “almost always” • most products used were passive products and tapes and bandages • pharmacists influenced patient choices 44% of the time and assistants 33% of the

time (cf 44% for hospital, doctor or nurse) • pharmacist was involved 78% of the time • most customers reported changing the dressing at least daily at some point in the

healing process • advice was given 55% of time (based on patient recall)

16

• majority of customers rated the pharmacies as excellent in meeting their overall wound care needs

• customer identified that would have liked a brochure or written instructions for later reference

1.7 CUSTOMER LOG The customer logs contained records for 197 customers seeking wound care and first aid. Of these, 2 did not have wounds (treating a wart, treating nappy rash) while no information about wound type was recorded for a further 2. For the remaining 193 customer entries, 15 were seeking products for sports, sprain or strain reasons and a further 26 wound/first aid entries were recorded after the 2 week data collection window was finished (see Table 1.8).

Table 1.8 Number of customers logged for each pharmacy

Site No. customers logged in 2 weeks

Number with wounds (exclude sprains/strains /sports related injuries) in 2 wks

Additional customers logged

M01 16 15 3 M03 5*† 5* M04 24 24 M05 9 6 M06 14 14 15 M08 3 2 1 R01 11 11 1 R02 5* 5* R04 12* 11* R05 21* 17* R06 9 7 6 R07 19 16 3 R08 19 19 3

* assumed to be 2 weeks since log entries not dated † Likely to be under-reported since at telephone interview, the pharmacist estimated that there were generally about 2 wound care customers/day. The remaining 152 customers had 153 reasons for purchasing wound or first aid products. For the 2 week period, products were mainly purchased for cuts and grazes, followed by surgical wounds and stitches (Table 1.9). The overall pattern of reasons for purchases did not change markedly when all wound care log records (not sports etc) were included. There were differences, however, in the pattern between the various pharmacies for the 2 week period of the customer log reporting. The pattern for a pharmacy also changed slightly when the wound log was kept for a longer period of time (records marked with * in Table 1.9). Overall, 26% of products sold for first aid or wound care purposes in a 2 week period were for passive dressings, while 17% were tapes and bandages (that might be required to keep passive dressings in place) (Table 1.10). When all transactions recorded on the log were included (including sports-related purchases), proportions of passive dressings and tapes and bandages were 24% and 21% respectively. The range of wound care products sold varied markedly between pharmacies. One site sold only passive dressings, simple first aid and tapes and bandages, while another site had sold dressings in every class except simple first aid.

17

Table 1.9 Reasons for wound/care first aid purchase from the customer log for each pharmacy in a 2 week window

% of wound care customers seen in 2 weeks Site None (for




Other wound type

Don't know

M01 26.7 33.3 13.3 6.7 6.7 13.3 M01* 33.3 27.8 11.1 11.1 5.6 11.1 M03 20.0 20.0 60.0 M04 37.5 20.8 20.8 12.5 8.3 M05 50.0 16.7 33.3 M06 26.7 26.7 20.0 6.7 6.7 13.3 M06* 20.0 26.7 23.3 10.0 6.7 13.3 M08 50.0 50 M08* 33.3 33.3 R01 9.1 9.1 9.1 36.4 18.2 18.2 R01* 8.3 8.3 8.3 41.7 16.7 16.7 R02 50.0 16.7 33.3 R04 25.0 16.7 25.0 16.7 8.3 8.3 R05 64.7 11.8 23.5 R06 14.3 57.1 14.3 14.3 R06* 10.0 60.0 10.0 20.0 R07 18.8 31.3 12.5 6.3 18.8 6.3 6.3 R07* 16.7 27.8 11.1 5.6 22.2 5.6 11.1 R08 5.9 29.4 5.9 11.8 29.4 5.9 11.8 R08* 5.0 30.0 5.0 20.0 25.0 5.0 10.0 Overall 5.9 35.3 15.0 10.5 19.0 7.8 6.5 Overall* 6.1 34.8 14.9 12.2 18.2 7.7 6.1

* including the wounds reported after the 2 week window

Table 1.10 Products sold as recorded on the customer log

% of total dressings sold in 2 weeks/site excluding sports related purposes Site Algin-



Hydro-gels


Passive dress-ings

Polymer dress-ings

Scar reduct-ion


Tapes & band-ages

M01 8.3 4.2 4.2 16.7 29.2 16.7 20.8 M03 9.1 9.1 9.1 63.6 9.1 M04 2.8 5.6 16.7 5.6 5.6 5.6 5.6 19.4 11.1 5.6 16.7 M05 10.0 30.0 40.0 20.0 M06 21.9 3.1 15.6 21.9 3.1 21.9 12.5 M08 33.3 33.3 33.3 R01 6.3 12.5 12.5 12.5 12.5 37.5 6.3 R02 27.3 18.2 18.2 9.1 9.1 18.2 R04 25.0 62.5 12.5 R05 11.1 22.2 25.9 11.1 29.6 R06 22.2 22.2 11.1 11.1 33.3 R07 5.6 11.1 5.6 16.7 27.8 33.3 R08 19.2 3.8 11.5 53.8 11.5 Total 1.3 1.7 15.1 2.5 2.5 7.9 10.5 25.9 2.1 1.3 12.1 17.2

18

Staff were asked to indicate whether the customer’s choice of product was influence or even changed by the staff member. For customer log entries in the 2 week period, 164 entries recorded this data. Overall, for 10% of transactions, a change in customer choice was reported, while on average, the pharmacist was consulted for 36% of transaction, and customers were referred on in an average of 16% of cases.

Table 1.11 Interactions with customers, consultation with the pharmacist and referral

% of customers with valid log record for a wound in 2 weeks Site Influenced

customer choice Changed

customer choice Pharmacist

asked Referred on Referred on

(count) M01 93.33 40.00 80.00 13.33 2 M03* 100.00 0.00 20.00 20.00 1 M04 69.57 17.39 37.50 0 0 M05 55.56 0 28.57 0 0 M06 73.33 33.33 30.77 28.57 4 M08 0 0 0 0 0 R01 45.45 0 36.36 0 0 R02 66.67 20.00 100.00 25.00 1 R04 58.33 0 16.67 33.33 4 R05 52.38 6.25 47.62 26.32 5 R06 77.78 0 14.29 11.11 1 R07 43.75 0 12.50 25.00 4 R08 57.89 10.53 38.89 22.22 4

* incomplete customer log suspected

1.7.1 APPROPRIATENESS OF PRODUCTS PROVIDED

The advanced dressings (foams, alginates, hydrocolloids and hydrogels etc) were more consistently given a higher appropriateness rating as a facilitator of wound healing and there was little difference between sites for the appropriateness ratings for these products. Appropriateness ratings for passive dressings, first aid products, other dressing related products and tapes and bandages were more varied overall and between the sites. In short, where a passive or first aid dressing was supplied, it was probably not very appropriate as an aid to wound healing.

1.7.2 COMPARING WOUND TYPES SEEN IN 2 WEEKS WITH ESTIMATES

The estimates made by the proprietor/manager and the average of pharmacy assistant estimates of the proportion of wound types seen in each pharmacy were compared with the percentage of wound types seen in the two week period of the customer log. There was little agreement between any of the measures for individual sites. This lack of agreement might be partly explained by a 2 week period not capturing a representative customer sample but there is likely to be error in the estimates since there was no agreement between proprietor and assistant estimates of the percentage of customers presenting with each wound type. The areas with lack of agreement are shown for each site (see Figure 1.5 to Figure 1.9).

19

M01

0

10

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80

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

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Log

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PA M

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Log

Prof

ile

PA M

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Log

Prof

ile

PA M

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Log

Prof

ile

PA M

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Other wounds

% o

f wou

nd c

are

cust

omer

s * PA Mean based on single response to pharmacy assistant quiz

M03

0

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Log

Prof

ile

PA M

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Prof

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ile

PA M

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Log

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ile

PA M

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Log

Prof

ile

PA M

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Other wounds

% o

f wou

nd c

are

cust

omer

s * Log possibly incomplete since only 5 customers

M04

0

10

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80

Log

Prof

ile

PA M

ean

Log

Prof

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ean

Log

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Log

Prof

ile

PA M

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Log

Prof

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Log

Prof

ile

PA M

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Other wounds

% o

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nd c

are

cust

omer

s



20

M05

0

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80

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

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Log

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ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean



Other wounds

% o

f wou

nd c

are

cust

omer

s

M06

0

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50

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80

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

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ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean



Other wounds

% o

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nd c

are

cust

omer

s

M08

0

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80

Log

Prof

ile

PA M

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Prof

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PA M

ean

Log

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ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

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Log

Prof

ile

PA M

ean



Other wounds

% o

f wou

nd c

are

cust

omer

s



21

R01

0

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60

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80

Log

Prof

ile

PA M

ean

Log

Prof

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PA M

ean

Log

Prof

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PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

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PA M

ean



Other wounds

% o

f wou

nd c

are

cust

omer

s

R02

0

10

20

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50

60

70

80

Log

Prof

ile

PA

Mea

n

Log

Prof

ile

PA

Mea

n

Log

Prof

ile

PA

Mea

n

Log

Prof

ile

PA

Mea

n

Log

Prof

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PA

Mea

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Log

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PA

Mea

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Other wounds

% o

f wou

nd c

are

cust

omer

s

R04

0

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Log

Prof

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PA M

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Log

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PA M

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Log

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PA M

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Log

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PA M

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PA M

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Other wounds

% o

f wou

nd c

are

cust

omer

s * Only log data completeMissing data for pharmacy assistant quiz (PA Mean) and all but 2 profile responses


pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – R01, R02 and R04

22

R05

0

10

20

30

40

50

60

70

80

Log

Prof

ile

PA

Mea

n

Log

Prof

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PA

Mea

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PA

Mea

n

Log

Prof

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PA

Mea

n

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Prof

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PA

Mea

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Other wounds

% o

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are

cust

omer


R06

0

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Log

Prof

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PA

Mea

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Mea

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Other wounds

% o

f wou

nd c

are

cust

omer


R07

0

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80

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

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PA M

ean

Log

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ile

PA M

ean

Log

Prof

ile

PA M

ean

Log

Prof

ile

PA M

ean



Other wounds

% o

f wou

nd c

are

cust

omer

s * Only log data completeMissing data for pharmacy assistant quiz (PA Mean) and profile

Figure 1.8 Comparison of customer log, pharmacist (per profile) and the average pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – R05, R06 and R07

23

R08

0

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30

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80

Log

Prof

ile

PA M

ean

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ile

PA M

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Other wounds

% o

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s


pharmacy assistant (per pharmacy assistant quiz) estimates of the percentage of wound care customers with various wound types – R08

2. INDEPENDENT QUALITY MEASURES 2.1 MYSTERY SHOPPER VISITS The mystery shopper visits took the form of a product request. Few sites actually sought more information from the customer that might have been used to help the customer choose a more appropriate dressing than the passive dressing, Melolin. Four sites sought information about the size/location/appearance of wound (M06, R01, R05, R07) while one site gained information about the duration of wound (R05) (reported as ‘volunteered’ by the shopper). Six sites were recorded as providing information or advice about product selection or use: • That tape was needed to adhere Melolin (M08, R05) • That the shiny side of the Melolin should be placed onto the wound (M06, M01) • Economy issues i.e. buy a larger size and cut to size (M01); cost box versus singles (R02) • Discussion on whether needed waterproof dressing (scored as advice not information

seeking) (R07) No site offered more than 2 pieces of relevant advice, although there were 4 categories listed on the form. Three sites both sought information and gave advice, although neither were carried out at a high level since none explored the potential risks for poor wound healing and how to promote healing. At 2 sites (R06, M04), the mystery shoppers at the wound care section were ignored by the pharmacy assistants.

2.1.1 MYSTERY SHOPPER SCORES

The mystery shoppers’ global rank of the shopping episode was compared to the mystery shopping score. As expected, the ranking and ratings were highly correlated but since the correlation coefficient was less than 1, these two variables were felt to address overlapping but different domains of service quality.

24


76543210

Mys

tery

sho

pper

rank

ing

16

14

12

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8

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R08

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R01

M11

M08

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M05M04

M03

M01

Figure 2.1 Comparison of mystery shopper score and mystery shopper rank for

each study site (dashed line = linear regression line of best fit)

2.2 INDEPENDENT QUALITY SCORES Several different quality measures were used in the pilot study. These measures covered various domains of the broad concept of service quality: • The mystery shopper score emphasised information seeking and advice by the pharmacy

assistant (or pharmacist) as part of the service experience. It did not attempt to assess the appropriateness of any advice. The mystery shopper rank included some of the same aspects as the score but also extra, intangible aspects of the shopping experience, such as being ignored by nearby assistants when the shopper was at the wound care section, or a display of reluctance when a receipt was requested.

• The auditor’s perception of service quality on 4 dimensions were largely based on how the wound care section looked, the stock carried, aids to customer self-selection and how space and facilities appeared to meet the needs to the pharmacy.

• How appropriateness of products sold in a 2 weeks were likely to be in facilitating wound healing. Is the pharmacy selling the most appropriate dressing to a customer?

The independent quality score linked the mystery shopper rank and score and the audit overall quality score. This independent score increased as the following ratings increased: • Audit service level rating (rudimentary to advanced) • Audit space and facilities needs met rating • Audit display aids self-selection rating The combined quality score was calculated so that the mystery shopper episode, the audit overall quality rating and the mean appropriateness were equally weighted i.e.

independent quality score + (mean appropriateness score x 100/3) 3 A summary of scores across the range of independent quality measures is shown in Table 2.1. These measures, and the remaining 3 audit quality assessments, were compared against potential indicators.

25

Table 2.1 Summary of overall quality measures per site

Site

Mystery shopper rank

(max 14)


(max 9)


(max 100)


(max 200)

Mean appropriate-ness rating of

products sold (max 3)

Combined quality score

(max 100) M01 14 5 95 158.33 2.36 78.97 M03 4 2 91 111.00 1.50* 53.67* M04 6 1 83 106.33 2.13 59.14 M05 7 2 43 73.00 1.07 36.24 M06 13 6 50 113.33 2.08 60.93 M08 9 4 30 73.33 1.17 37.41 M11 2 2 17 30.33 - 21.22† R01 12 5 43 99.67 1.75 52.67 R02 8 3 64 100.67 1.45 49.67 R04 5 1 22 42.00 1.13 26.59 R05 11 6 69 125.67 0.94 52.38 R06 1 1 44 50.67 1.75 36.33 R07 10 4 51 97.67 1.12 44.95 R08 3 1 50 63.33 1.07 33.02

* likely incomplete data collection † since no log was provided, the median average appropriateness score (1) was imputed and a combined score calculated

3. INDICATORS VERSUS INDEPENDENT QUALITY MEASURES

3.1 PHARMACY CHARACTERISTICS Key outcomes with regard to pharmacy characteristics were:

• The location of a pharmacy (rural versus metropolitan) did not significantly influence independent quality measures

• After excluding the 3 more advanced wound care pharmacies, (all metropolitan), the median combined quality score for metropolitan pharmacies was lower than that of rural sites, although not significant.

• Pharmacy size did not influence the quality ratings. • Only significant relationship for banner group pharmacies was a significantly lower

mystery shopper score than non-banner group sites. • Quality Care Pharmacy Program accreditation was only significantly related to the

extent to which space and facility needs were met (median score accredited=55, non-accredited=26) and the arrangement of the wound care display to aid self-selection (median score accredited=41, non-accredited=13).

3.2 LAYOUT OF WOUND CARE SECTION The following features of the physical layout of the wound care section were found to correlate significantly with different quality assessments.

• The signage of the wound care area of the pharmacy was significantly related to perceived quality assessments at audit with a trend for higher quality scores in sites where the signs read “wound care” compared to no sign or a sign that read “first aid” (Figure 3.1).

26

• The further the pharmacist had to walk from the dispensary to the wound care section, the higher the average appropriateness rating of products sold but this may be related to the amount of shelf space occupied by wound care products which also increased as the average appropriateness rating of products sold

• While the amount of shelving for first aid products and the total amount of dressings shelving did not correlate with quality measures, the percentage of total dressings shelves for wound care shelves was related to the independent quality score.

• The arrangement of products in terms of neatness and layout was related to some quality measures

• The extent to which the wound care products were together and not dispersed among first aid products and tapes was related to the audit overall quality level, the independent quality score and combined quality score

• Three audit assessments, service level, space and facilities and display to aid self-selection were related to product arrangement.

• Similar trends were observed for the extent to which different products could be distinguished just by looking at the shelves.

• The audit overall quality rating, independent quality score and the combined quality score increased as the layout improved as did the other 3 audit assessments, service level, space and facilities and display to aid self-selection.

446N =



Ove

rall

qual

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ting

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0446N =



Serv

ice

leve

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446N =



Spac

e &

faci

litie

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0446N =



Dis

play

aid

s se

lf-se

lect

ion

120

100

80

60

40

20

0

p=0.170 p=0.120

p=0. 076 p=0.027

Figure 3.1 Boxplots comparing quality assessments at audit for the type of signage

of the wound care section

3.3 PHARMACY CHARACTERISTICS AND WORKLOAD The total number of opening hours was related to the audit overall quality score, the independent quality score and combined quality score. (Figure 3.2) These relationships were

27

still significant after the benchmark site with the longest opening hours was excluded. Similarly the audit quality measures (overall, service level and display) and the independent and combined quality scores all increased as the number of prescriptions filled per week increased. Since opening hours and number of prescriptions dispensed are highly correlated with shop size and turnover in Australian community pharmacies, the relationship between independent and combined quality measures and opening hours and script numbers probably reflects a strong relationship between the size of the business entity and audit overall quality ratings. Note that the audit overall quality rating is strongly related to the size of the wound care display and other observational aspects of service quality. The service dimensions measured by the mystery shopper visit and the appropriateness of products sold was independent of the business-size related measures, so that both small and larger pharmacies have the potential to perform well on these measures.

Opening hours/week

120110

10090

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R08R06

R05

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M11

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M03M01A

Figure 3.2 Opening hours per week versus A. Audit rating of overall service quality,

B. Independent quality score and C. Combined quality score

Other key pharmacy characteristics related various independent quality assessments include: • The number of EFT pharmacists did not relate to any quality measure but the number

of pharmacists (irrespective of whether full-time or part-time) was related to audit quality measures and the independent and combined quality scores

• Total pharmacist hours per EFT pharmacist was not related to any quality measure • The number of EFT assistants was only related to audit overall quality ratings

3.3.1 PROPRIETOR/MANAGER PERCEPTIONS OF SERVICE AND QUALITY

The level of agreement between the proprietors’ perceptions of quality and the independent quality measures was slight. As the proprietors’ rating of overall service quality increased, so to did the average appropriateness rating of products sold and the combined independent quality score. The availability of written wound care information that customers could take away was not significantly related to any quality measure, nor were proprietor’s reports of assistants seeking pharmacist input into wound care transactions, taking a detailed history of a wound or persuading customers to select a more appropriate product. Here, proprietor reports are at odds with the findings from the customer log where some relationships were seen between quality an customer influence (see section 3.5). Pharmacies where there was an opportunity to monitor wound healing progress because wound care customers were seen more than once did not have significantly different quality ratings than those without this opportunity. Of the pharmacies that had the opportunity to monitor wounds, there was no difference in any quality measure for those that routinely monitored progress in a given episode of wound care

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and those that did not, perhaps because this indicator was based on proprietor reports of practice patterns not objective evidence of progress monitoring.

3.3.2 STOCK AND SALES

As the proportion of turnover made up by wound care increased, the combined quality scores significantly increased. The range and level of stock carried as recorded at audit (since there was no missing data for this measure) was compared against the quality measures. Two aspects of stock holding were considered, the range of stock carried (a combination of number of brands carried and number of different dressing sizes) and a stock level score (stock range and the quantity of stock carried). The relevant significant findings here are:

• A broader stock range was positively correlated with an increase in the audit overall quality rating and the service level rating

• Presence of more specialist dressings (eg polymer, alginate and hydrofibre dressings, and zinc paste bandages) positively influenced the audit quality rating

• Greater stock ranges of foam, polymer and hydrofibre dressings and zinc paste bandages were a marker for the sale of more appropriate dressings.

• The combined quality score increased as the stock range score for polymers and alginates and the total stock range score increased.

• The stock range scores of films, hydrocolloids, hydrogels and cadexomer iodine were not related to any quality measure as they were widely carried

• The stock range scores for passive dressings and first aid products did not differ between sites and so were not related to any quality measure.


Training in wound care and the effects on service quality were interesting and seem to reflect the fact that pharmacy assistants have a significant role to play in the service provision.

• As the number of pharmacy assistants with any wound care training increased, the audit overall service level rating, the appropriateness of products sold and the combined quality score increased.

• Similar relationships between quality measures and number of recently trained assistants were seen.

• The number of pharmacists undertaking wound care professional development in the last 2 years was not related to any quality measures. The influence of any pharmacist wound care training was not assessed but the quiz findings (3.4) suggest that increasing pharmacist knowledge may also increase quality.

3.3.4 POLICIES AND PROCEDURES MAINTAINED

Patient wound care records were kept by 4 of 11 pharmacies responding to the question (M01, M06, M08, R01), and these sites were associated with significantly a higher combined quality score. The percentage of the 11 different wound care policy/procedure types that each pharmacy had as a written policy was not correlated with any quality measure, nor was the percentage of policies that were unwritten. This finding was based on reports of policies/procedures and should be interpreted with caution.

3.4 QUIZZES Key findings from the comparison of quiz results and the quality measures were:

• A significant relationship between audit overall quality rating and pharmacy assistant quiz scores was identified

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• The pharmacist quiz scores were related to audit quality measures and the independent and combined quality scores

3.5 CUSTOMER LOG Information on wounds seen at the community pharmacy was obtained from pharmacist estimates via the wound care profile, pharmacy assistant estimates via the quiz and the presentation recorded on the customer log. Pharmacies that estimated and saw (per the log) a higher number of burns presentations to the pharmacy achieved higher quality ratings across a range of measures. Quality measures were also compared to the percentage of the various dressing categories sold per the log, and the percentage of dressings sold that were not passive or first aid dressings, tapes or other dressings.

• Higher sales of hydrogels were associated with higher quality score across a range of measures.

• Higher sales of cadexomer iodine was associated with higher average appropriateness of products sold and a higher combined quality score.

• Higher percentage sales of passive dressings was generally associated with lower quality scores and increased sales of simple first aid products also showed a trend towards decreased quality ratings

• The higher the percentage sales of dressings that were more than just passive or first aid dressings or tapes or other dressings, the higher the average appropriateness score for dressings and the combined quality score.

The involvement of the pharmacy staff in the product selection made by a customer was classified in terms of influencing choice and changing choice. Pharmacies where a greater percentage of customers had their choice influenced had higher quality ratings for two audit measures and the average appropriateness of products sold. Actually changing customer choice was associated with higher levels across more of the quality measures. Similarly, as the proportion of customer episodes in which the pharmacist was consulted increased, so too did audit quality measures and the independent quality score. Interestingly, consultation with the pharmacist was not related to the average appropriateness of products sold.

CONCLUSION This research has allowed comparisons to be made between sites for benchmarking purposes as well as producing data on factors which influence outcomes that may be considered as part of the Continuous Quality Improvement cycle. There is potential to improve both patient and practice outcomes as well as optimise the wound care area as a core business activity with the potential for fostering growth in the area. The detail of each of the measures and comparisons that are described in this report can be found in the complete report for the Pharmacy Guild. This report will include all statistical outcomes of relevant measures. This report will be accessible via the Guild website after it has been accepted (late 2003). The researchers are very grateful to all the pharmacies and their staff who participated in this study and hope that this report provides some benefit through practice and business development.

wound care benchmarking in community...

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