President's Message - Reflection and Transformation
by Chris Rivers, ICHP President
February 15, 2012
The new year has begun, and 2011 is history. Resolutions have been made (and/or broken), but every year we move forward and hope for a better year. The Chicago Bears’ season is over. Time for college hoops and Chicago Bulls (or any team you are cheering for). This is the Presidential election year, and we are in the midst of caucuses and primaries.
It is a time for reflections and resolutions in our career and our practice.
Reflecting back over 20 years ago when I was conferred the Bachelors of Science in Pharmacy, it was an education comprised of 2 years of pre-pharmacy followed by 3 years of pharmacy education. Residency training, although I opted out temporarily, was uncommon. Pharmacy practice has evolved from compounding and medication dispensing. Automation was a new vocabulary word. A hospital with decentralized clinical pharmacy services, or one with a pharmacokinetics or nutrition service, was rare. Our profession has transformed into one with highly trained clinicians working in clinical areas including critical care, pediatrics, emergency, ambulatory care and others.
Some of us attended the ASHP Midyear Clinical meeting early December. The theme was the acronym NOLA in New Orleans: Networking, Opportunity, Learning and Advancement. NOLA’s agenda included programming for distinct groups like small and rural hospital pharmacists, students and new practitioners. There were sessions that showcased the development of the future of pharmacy practice through implementing the goals of the Pharmacy Practice Model Initiative (PPMI).
As a federal civilian employee of the VA, I attended the Sunday afternoon Federal Forum session. The session showcased the innovations that this segment of the workforce has embraced to improve, advance and transform the profession in support of the PPMI goals.
Dr. Mark Woods, Clinical Coordinator and Residency Program Director from St. Luke’s Hospital in Kansas City, Missouri, addressed the keynote speech. He highlighted the history of pharmaceutical care, starting with the legacy of the consensus conference at Hilton Head in 1985. One of the first reported projects was the Asheville Project in 1997. The North Carolina Center for Pharmaceutical Care was formed by pharmacy leaders and collaborated with the city of Asheville to offer pharmaceutical care services to diabetic city employees. Significantly more patients reached the hemoglobin A1C goal of less than 7% in the combined groups of Asheville along with St. Joseph’s Health System, at follow-up compared to baseline. This was followed by the implementation of pharmaceutical care in 1993 at the San Antonio conference. The momentum gained in the past decade under ASHP President, Kevin Colgan. In 2008, the ASHP board authorized the PPMI committee. The PPMI Summit was held in Dallas in November 2010. The goal of the summit was to “create a passion commitment and action among hospital practice leaders to significantly advance the health and well- being of patients by optimizing the role of pharmacists in providing direct patient care”. This led to the PPMI consensus conference and goals.
The main goal is to stimulate practitioners to build optimum models for their particular department or setting. This is not to develop a “best” model for all hospitals but to identify resources that can assist in the examination and implementation; identify models that are currently in operation that may serve as role models; and identify barriers to reform.
The model describes the way pharmacy departments, pharmacists and technicians, and resources are deployed to provide current patient care services. It includes the deployment of automation and technology in the medication use system. Examples of Federal Pharmacy Practice Models include the Veteran’s Administration ambulatory care services and credentialing programs, US Army Wounded Warrior Program, Army Technician Training Program, Federal pharmacy residency training programs, and the VA medical record and medication use review capacities.
Dr. Woods expressed because there is minimal consistency in the nomenclature of defined models, this makes the description of optimal practice models difficult.
The ASHP National Survey of Pharmacy Practice in hospital settings described 3 distinctive practice models:
1) Drug distribution model: pharmacists engage primarily in drug distribution and reactive order processing,
2) Clinical specialist model: pharmacists engage in clinical activities with medical teams on nursing units but may have little or no responsibility for issues related to medication use or drug delivery systems,
3) Patient-centered integrated model: pharmacists accept responsibility for both clinical and distributive activities. In this model the pharmacist’s clinical role is enhanced because well-trained technicians manage most drug distribution processes. This results in pharmacists being proactively engaged in medication use and selection with an interdisciplinary team and exhibits a high degree of ownership/accountability for medication use processes.
Of the 518 respondents to the aforementioned survey, 25.8% indicated they practiced in a drug distribution model, 63.5% indicated they practiced in a patient centered integrated model, and 10.7% indicated they practiced in a clinical specialist model. The limitations about practice model definitions is that one size does not fit all organizations; the practice in most organizations is a blend of the currently described practice models; one practice model best describes an organization’s practice philosophy; practice models will continually evolve in response to economies, technology and personal preferences of patients and practitioner; and we must be careful in defining terms so as to not confuse constituents (“comprehensive or hybrid models”).
What are the drivers of practice model change? These include the vast problems associated with medication use that result in patient harm and unnecessary expense; a system that is unsustainable that will require collaboration to set new directions; pharmacy’s moral ethical and social obligation (the need to use pharmacy resources rationally; stop doing work that can be done by non-pharmacists; becoming accountable for outcomes of patient care activities); and the expectations of key constituents (e.g., patients, physicians, administrators, regulators, students, residents).
One group of drivers are the new practitioners. Hospital Pharmacy
published the results of a survey of 497 new practitioners. The respondents assessed 21 tasks selected to represent the daily duties of health-system pharmacists: operational, clinical, and administrative. When they were asked the five most desired pharmacist roles and responsibilities, more than 90% responded they wanted to make adjustments of medication dosage based on disease response or pharmacokinetics; monitor response to therapy based on lab test values, progress notes and observation; mentor and/or precept students and residents; review patients’ medication profiles; and collaborate with multidisciplinary teams on non-critical care patient rounds.
Inversely, the least desired tasks were: entering physician orders into computers; dispensing medications; checking medications and products prepared by technicians; managing pharmacy operations; supervising technicians; and reviewing medication orders before a first dose of medication is administered. Practice models that best address new practitioners’ preferred activities may be better able to recruit and retain new practitioners.
Dr. Woods highlighted the unique opportunities available within the Federal Services for young pharmacists including opportunities to practice to their level of training (or “practicing at the top of your license”); engaging in unique collaborative practice agreements (scope of practice); creating new training opportunities within Federal services; and helping new practitioners answer their “calling”.
He encouraged sharing existing best practices of Federal Services with others through publications and posters, platform presentations, and involvement in local/state/national, PPMI forums and/or consensus conferences. Additionally, he advised increased training opportunities within the Federal Services including an increase in technician training, student clerkships, residency training (PGY1 and PGY2) and conducting research to study/identify best practices.
The use of the PPMI self assessment tool was recommended to engage staff to envision the future (http://www.ppmiassessent.org). Using the tool will help staff and administrators understand the urgency of the need for change from a model of staff satisfaction to staff engagement.
The highlights of Dr. Woods’ presentation will allow us to think about our own health-system department. I think the last section in Robert Frost’s poem “The Road Not Taken” summarizes the transformation of our profession: “Two roads diverged in a wood, and I— I took the one less traveled by, And that has made all the difference.”References
Brennan C, Donnelly K, Somani S. Needs and opportunities for achieving optimal outcomes from the use of medicines in hospitals and health systems. Am J Health-Syst Pharm.
Frost R. The Road Not Taken. Mountain Interval.
New York: Henry Holt and Company, 1920; Bartleby.com, 1999. www.bartleby.com/119/.html [accessed 2012 January].
Hertig JB, Kelley KA, Jordan TA, et al. Advancing the Pharmacy Practice Model: Survey of New Practitioner Attitudes and Opinions. Hosp Pharm
. 2011; 46: 180-195.
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2008. Am J Health-Syst Pharm
. 2009; 66:926-946.
Woods TM. Practice Model Challenge. Am J Health-Syst Pharm
. 2009; 66:1167.
Zellmer WA. Seeking “better ways” in hospital pharmacy. Am J Health-Syst Pharm
. 2009; 66:713.
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