Millcroft Hospital Pharmacy Leadership Conference - June 1 - 3, 2007

Theme:Scope of Pharmacy Practice - What Will the Future Look Like?

Group Reports:
Determining Our Preferred Vision

As groups reported back on results of their facilitated discussions, a cohesive vision of opportunities, challenges, and appropriate avenues for action began to emerge. As one representative noted, “We all agree it’s time for change. Now it’s time to move from reactive to proactive models to move forward.”
Speakers characterized moving forward as defining core services, using an evidence-based approach to isolate specific high-impact services, and then leveraging the results. Speakers identified several key directions:

•	Expansion of inter-professional collaboration across jurisdictions and sectors
•	Removal or delegation of drug distribution responsibilities
•	Alignment with other professions and with patient/client needs
•	Enhancement and standardization of education and training
•	Collaboration among hospital pharmacy leaders and existing organizations, with clear evidence-based leadership

Group members spoke of ways to meet the goal of “getting hospital pharmacists out of the dispensary so they can fulfil their professional potential.” Clear minimum standards for the management of drug distribution must be set and clearly communicated.
Comprehensive change management plans must be developed that are flexible enough to be adopted by both small and larger hospitals. Pharmacists themselves have to be more willing to delegate distribution responsibilities, either to technology or to other technicians. Better education and certification for pharmacy technicians will help increase pharmacist willingness to delegate. As one participant pointed out, “No one expects a dietician to work in the kitchen, so it shouldn’t be such a leap to accept that a pharmacist’s role unfolds outside the dispensary.”

Each group stressed the importance of expanding collaborative practice and broadening collaboration in general. Hospital pharmacy leaders were directed to identify and facilitate high-value pharmacy services and then collaborate with other health care professionals, regulatory agencies, public organizations, and educators. The collaboration should aim to create innovative and responsive models for advanced pharmacy practice, develop appropriate inter-professional education opportunities, and promote the acceptance of the advanced roles. Participants placed particular value on working more closely with nursing professionals. Noting the lack of a single clear leadership body for pharmacy, participants recommended developing a marketing plan for pharmacy services with roles for all partners, and suggested regulatory bodies should take the lead in developing consistent messages.

Frontline pharmacists must become engaged in this endeavour. One participant identified a message that needs to be communicated to colleagues in the profession: “We aren’t telling people what to do, but helping to lead in the direction that health care evolution and evidence-based practice is taking the profession.”

Alignment was a consistent theme across all the groups. Pharmacy service provision should be aligned with patient need. The locating of pharmacy services should allow for greatest impact. Impact should be the criteria for deciding when pharmacy services should be located in hospital emergency wards or special-care clinics, within which geographical setting, and where across the continuum of services the role should be advanced and where it should be kept traditional.

Pharmacy practice structures must be aligned with those of other professionals to ensure that inter-professional teams thrive and provide the highest possible level of care. This alignment must be based on clear evidence. Coherent efforts should be undertaken to gather all existing evidence about advanced pharmacy practice, identify evidentiary gaps, and facilitate needed additional research. Among other things, a minimum acceptable pharmacist-to-patient ratio should be established. “It’s not necessary to reinvent the wheel, but it would be nice to know how many tires we have, how many we need, and which might be a little flat,” a participant said.

Groups also recommended that hospital pharmacy leaders optimize current resource allocation to ensure staffing in key priority areas. Tools like the Hospital Pharmacy in Canada Report can be used to identify gaps where allocation does not match the resources. Participants spoke against a leadership style that works in isolation and “silos.” Instead, leaders should promote hospital pharmacy and negotiate services and resources to support its expanded utilization. The key to advancing patient-focused clinical practice is to align payment models so that pharmacists are paid for more than dispensing. Appropriate evidence-based resource allocations should also be represented in CCHSA standards.

One group recommended that pharmacists be assigned to the principal points of entry in the health care system to act as “knowledge brokers.” They defined knowledge brokers as key individuals who know key evidence and help translate it into clinical practice, using evidence-based decisions to form care plans. Pharmacists are ideally positioned to fill this role because of their long history of using evidence to determine appropriate drug use.

Each group called for improved education and training and for the adoption of consistent credentials, accreditation, and standards of practice. Training opportunities for graduates, undergraduates, and post-graduate specializations should be increased and enhanced. A comprehensive audit of available opportunities would be a good first step in determining effective educational models and remaining gaps. Both educators and students must be engaged in this process.

Participants underscored the importance of increasing opportunities for clinical training and strengthening requirements for clinical practice prior to certification. They directed CCHSA, NAPRA, and the Colleges to create accountability mechanisms to ensure that performance standards are being met. One group called for consideration of an apprenticeship approach, perhaps based on the model used by professional engineers.

Syme spoke of the Canadian Hospice Palliative Care Society’s Square of Care model. The patient is positioned at the centre of the model and is the reference point for decision-making, such as defining core services and identifying educational and training strategies.

Participants expressed agreement for establishing a national standard for pharmacy tiers and titles across the country. Some proposed starting with standards that already exist, such as those developed by CSHP and the Institute for Health and Social Policy, and then working with NAPRA and other Colleges to derive a national standard. One group delineated a process to ensure that standards continue to evolve with accreditation: build on the Blueprint for Pharmacy and create a biannual review to identify gaps or mismatches between priorities and standards and to help under-resourced organizations meet existing standards.

Groups stressed the importance of providing inter-professional education experiences, both inside the classroom and in clinical residencies. Two universities were specifically mentioned as models of successful inter-professional training—McGill University, even though it lacks a pharmacy program, and Memorial University.

Group members asserted that progress would only be made on all fronts by identifying the existing base of evidence and the gaps that still need to be filled. They called for a common toolkit to be made available to everyone across the country. The toolkit must be built upon the strong base of existing evidence and experience, while incorporating innovation and evolutionary development. Group members noted that the push to drive hospital pharmacy into more active interdisciplinary clinical practice started more than 40 years ago. The challenge for today’s leaders is to take advantage of a confluence of internal and external factors and leverage the unique benefits pharmacy has to offer. It is time for the profession to take its rightful place as part of an integrated, inter-professional approach to health care.