Joseph Smotherman, PharmD, is a lone pharmacist in a field traditionally dominated by nurses. Being the only pharmacist to ever have the title of Director of Quality at White River Medical Center in Batesville, AR, and the only pharmacist in Arkansas with this role in a hospital, gives Smotherman a distinct advantage when it comes to promoting pharmacists as members of the health care team. “Once you step outside a traditional pharmacy role, people begin to watch and listen,” he said. “There aren’t that many pharmacists working in a quality department in a hospital, and this allows me to better promote the profession.”
Although it might be a challenge for some, Smotherman’s unique position is the perfect fit for him. Not only does he track and evaluate quality metrics, but he also understands how pharmacists at White River positively affect each of those metrics. “I follow anything from infection rates and length of stay to how many admissions we have each day,” said Smotherman. “Pharmacists are some of the most clinically trained and perfect people to be involved with improving quality metrics.”
White River Medical Center is a 225-bed community hospital and the flagship facility of the not-for-profit White River Health System in north central Arkansas. The medical center’s pharmacy department includes 10 pharmacists, nine pharmacy technicians, and one pharmacy resident.
Smotherman served as the medical center’s Director of Pharmacy for several years until 2011, when he was asked by leadership to move into his current quality role. “As the Director of Pharmacy, I had a sizable role in building teams and improving processes, but I had zero experience in quality,” Smotherman said. “The hospital’s leadership wanted me to come over to the quality side to give it a new perspective.”
He had no idea how much he could promote the profession of pharmacy by stepping out of the pharmacy department. “It’s easy to get lost in the shuffle if you are showing your value to people who already know your value,” said Smotherman. “But if you move into a role that no one expects, then they become more finely attuned to what you are and what you are not able to do. You’re not singing to the choir anymore.”
Once Smotherman was settled in his quality role, he was struck by how hypocritical it was to promote pharmacy roles among pharmacists. “I needed to be among other health care professionals to really show what pharmacists can do,” he said. Earlier this year Smotherman was elected to serve a 3-year term as a Quality Improvement Director of the Inpatient Quality Initiative (IQI) advisory board, which is part of the Arkansas Healthcare Quality advisory board. The Arkansas IQI program rewards hospitals that improve the quality of care according to the Arkansas Medicaid Program’s clinical priorities, including care coordination at discharge, obstetrics, and tobacco cessation. As a member of the panel, Smotherman helps draw up the quality measures that the program tracks and is involved with the entire process of how well the measures are working and what needs to be changed in the future.
“The board is nursing-dominated, so it’s good to have a pharmacist at the table in an organization like this,” said Smotherman.
Smotherman began his career in pharmacy in 1997. “It’s staggering to see how quickly things are changing and how that accelerated rate of change continues to grow and grow,” he said. With hospitals facing readmission penalties, value-based purchasing programs, and bundled payment plans connected to quality incentives, “health care is shifting from ‘we hope we did a good job’ to ‘here’s how we can prove we provided quality care not only to avoid penalties but to also gain incentives,’” explained Smotherman. In looking toward 2014, he expects things to change at an even more rapid rate. “In the big picture, health care quality has gone from measuring processes to trying to measure clear outcomes,” he said.
The catch, he noted, is that hospitals may have the right processes in place, but they might not be getting the right outcomes. Measuring and tracking quality metrics allow hospitals to have both great processes for quality and improved quality outcomes. “I think hospitals and human beings in general tend to measure our intentions rather than our results,” said Smotherman. “We meant well, but those days of subjectively measuring what you think you did are over. Now things are outcome-driven in regard to health care quality, and this is a complete paradigm shift from what I saw 7 years ago.”
Above: (L–R) Pamela Street, PharmD; Jennifer Crabtree, PharmD; and Joseph Smotherman, PharmD, discuss a patient who may qualify for White River Medical Center’s Med Key program. Below: Smotherman’s previous role as a Health-System Pharmacy Director along with his current role as Director of Quality, Infection Prevention, and Case Management, demonstrates the varied impact pharmacists can have across the entire continuum of patient care.
With change often comes new opportunities. At White River, pharmacists are intricately involved with improving quality metrics by reducing readmissions and providing intense medication counseling for high risk patients. In 2012, the medical center was awarded a grant for the Med Key project, in which pharmacists identify high-risk patients who meet certain criteria and provide medication counseling. During the counseling session, the pharmacist gives the patient a thumb drive free of charge that contains their current medication list. “The patient can take the thumb drive to their pharmacist, their physician, or any other health care professional,” said Smotherman. “It’s a way of educating the patients about their medications and communicating across the continuum of health care. Oftentimes the information we get from the patient is inadequate and fragmented, so our goal is to improve the communication of care in our community.”
According to Smotherman, this project positively affected the White River’s readmission quality metric. “Because some of these high-risk patients are on a lot of medications, they tend to be the folks that keep coming back to the hospital over and over, and pharmacists have been able to improve [this quality metric],” he said.
For the most part, pharmacists at White River are involved in every aspect of care. “We tried to move the pharmacists outside the pharmacy, not just in practice, but to also provide education to physicians and nurses,” said Smotherman. The end result is that pharmacists are involved in virtually every aspect of hospital quality.
One of Smotherman’s most important projects is launching and implementing an antimicrobial stewardship program. “If pharmacy and quality got married and had a child, it would be called antimicrobial stewardship,” he said. A large part of Smotherman’s role is tracking quality metrics, especially hospital-acquired infection rates. “If a patient comes in and they pick up an infection, that is something we caused, but with antimicrobial stewardship, we can use antibiotics more effectively and more judiciously to avoid creating new infections,” he said.
Currently the foundation for the program has been laid and all the small blocks are in place. Smotherman anticipates rolling out the program in 2014. “It’s a multidisciplinary effort between the quality department, pharmacists, physicians, and nursing. It has to be a collaborative process or else it won’t work,” he said.
In addition to monitoring antibiotic use in the hospital, Smotherman hopes to take the program into the community. “So much of the antibiotic distribution and prescribing takes place in the outpatient arena, so thinking ahead, once we get a good handle on it internally in the inpatient setting, the question becomes how do we as a quality department move outside our organization and into the community to influence some of the prescribing patterns of local physicians who not only send patients here but send patients home with antibiotics,” he explained. Smotherman hopes to move antimicrobial stewardship from an organizational process to a communitywide effort to get a handle on how antibiotics are used in the community.
Above: Pharmacy Manager Maggie Williams, PharmD, BCPS, Smotherman, and Street review White River Medical Center’s antibiogram. Below: Advanced drug distribution technology and informatics helped Smotherman and the team build a solid platform for enhanced patient care and pharmacist involvement at White River Health System.
As quality improvement takes center stage, Smotherman expects pharmacists to get more involved with reducing readmissions, play a bigger role in infection prevention, and provide insight into processes and outcomes.
“Pharmacists have three aspects of their training and experience that most health professionals don’t,” he said. Pharmacists have a clinical role, more financial experience than other providers because they know how to manage drug budgets and contract with wholesalers, and are good at figuring out processes. “Any time you insert a pharmacist with that skill set into anything that is going on, things should improve,” said Smotherman.