Pharmacy Leadership Challenges
Philip J. Schneider

Philip J. Schneider is Clinical Professor and Director of the Latiolais Leadership Program at the Ohio State University, an inter-professional program to optimize the medication use process and reduce adverse drug events. As the conference's facilitator, Philip gave an overview of Pharmacy Leadership Challenges.

Workforce Issues

Based on surveys in Canada and the U.S., there is a shortage of pharmacists in terms of available positions and the number of pharmacists. These workforce issues are repeated across the world and in many different professions, e.g. nursing and medicine. In hospital pharmacy, we need to improve our ability to compete in the market and to look hard at what we really do require. The major determinant in a pharmacist's decision to accept a position is an exciting vision in terms of what the department wants to accomplish and a commitment to achieve that vision. This doesn't mean there are no mundane aspects to the work, but overall the job is exciting and going somewhere.

Marketing our departments and our vision and working with students is essential for future success. When we are short-staffed, we tend to reduce time spent with students but this may be short-sighted. We need to re-engineer our work with automation and expand the use of technicians. There needs to be an emphasis on retraining staff and on retention through education and training programs. We need to improve performance appraisals and staff satisfaction by surveying for employee opinions and acting on them. We also need to thank our staff for a job well done as much as possible.

Leadership challenges

Leadership challenges in Pharmacy include:
· Expanded use of technicians
· Expanded use of technology and automation
· Physician order entry
· Leadership succession planning
· Medication error reduction strategies
· Seamless care

The premises underlying this discussion include the limited number of pharmacists, and the fact that pharmacists are expensive. There are problems with the medication use process in terms of efficacy and optimal use of medications, safety and the related public concerns, and limited resources particularly for new therapies. Most funding organizations consider health care a major drain on their resources and drug costs are a major portion of both the costs and the potential solution in avoiding hospitalization. Finally, we cannot expect to do everything - we need to decide what we will give up in order to accomplish our goals.

We need to listen more carefully to everything around us in order to understand what the market is telling us. For example, hospitals are no longer preferred employers so we need to determine how to make our hospital a great place to work. The public is concerned about safety, so we need to provide a service that people will trust. We need to understand what people want/need and where they want to receive the service. Today, the art of Leadership is becoming the art of listening and following what you hear. It revolves around the question of what are we trying to do versus what are others telling us they need.

From an American perspective, the quality issue is being spearheaded by the Institute of Medicine (IOM). The first report, "To Err is Human", focused on incidents and safety. The second IOM report is called "Crossing the Quality Chasm" and is a much broader look at healthcare. It examines the issues around redesigning health care in the U.S. It was produced because of significant evidence that there are serious quality shortcomings in care. There are many uninsured people, highly fragmented delivery systems, poor clinical information infrastructure that makes efficient communication difficult, overuse of many services such as lab tests, and an "era of Brownian motion" in health care.

The IOM report recommends a commitment to six aims for 21st century healthcare (the order in which they appear is important):
· Safety - avoiding injury first and foremost.
· Efficacy - evidence based care, appropriate use of interventions.
· Patient-centred care - take into account the patient's preferences, needs, values.
· Timely delivery of service - reducing waiting times and delays.
· Efficiency - avoid waste, some statistics say 50% of care is wasted.
· Equitable - quality of health care does not vary by location, patient population.

The report also recommends ten rules for redesigning healthcare. Care must be based on a continuous healing relationship with an emphasis on prevention and a proactive approach. Customization of care is based on patient needs and values. Patients are involved in their own care and act as the source of control. Shared knowledge and the free flow of information between care providers must happen, for example access to lab values and allergy information when entering medication orders would reduce adverse events. Evidence-based decision making and safety should be seen as system properties. We need to think about a hospital the way we think about airlines and build systems with concern for preventing unlikely events. There is a need for transparency with review of sentinel events and openness in discussing why they occur and what will be done about them. We need to anticipate needs. There has to be a continuous decrease in waste in the system. And finally, there must be cooperation among clinicians.

Challenges in achieving this vision include an institutional commitment to the redesign of care processes based on best practices. We need to increase the use of information technologies (IT). Most hospitals have invested 1-2% of operating funds in IT, whereas most information based industries invest 10% and have done so for years. In the current climate of funding constraints this is hard to do. There also has to be knowledge and skill management, development of effective interdisciplinary teams, coordination of care with respect to timing and care settings and effective performance and outcome measurements.

Priority medical conditions were identified by the Medical Expenditure Panel. As pharmacists, we need to examine this list and determine where we can make a difference, e.g. cancer care, diabetes, anticoagulation, lipid management, hypertension, asthma. The list in order of priority is:
Cancer
Diabetes
Emphysema
High cholesterol
HIV/AIDS
Hypertension
Ischemic heart disease
Stroke
Arthritis
Asthma
Gall bladder disease
Stomach ulcers
Back problems
Alzheimer's disease
Depression
Anxiety disorders

To prepare the workforce for the future of health care, we need to restructure the clinical education of health professionals and assess the implications for credentialing and educational programs. For pharmacists, the ability to be reimbursed for cognitive services will be crucial.

The Improvement Model

This model was developed by Langley, Nolan and Nolan in order to improve the delivery of health care. The model has 3 aspects:
· Aim - What are we trying to accomplish? What is the unmet need? Require evidence there is a problem that needs to be fixed, e.g. ensure patients do not receive agents to which they have a known allergy.
· Current knowledge - How will we know a change is an improvement? What specific measurement system will we use?
· Cycle for learning and improvement: What changes can we make that will result in an improvement? Improvement always involves change but not every change will result in improvement. A plan is developed based on hunches and a small scale test is performed to verify the plan. Data is collected over time and finally we act to spread change or try something else. It is not realistic to expect improvements while remaining with the status quo.

The medication use process is complicated and not easy to change. There are many steps in the process - prescribing, dispensing, administration and monitoring. As pharmacists, we have seldom focused on the prescribing and monitoring steps and have traditionally looked mainly at the dispensing and administration aspects. We need to consider all aspects of the process in developing our aims.

Ohio State University's Clinic Pharmacy has developed eight goals to explain "Why Are We Here?"
· Patients should understand the benefits and risks before receiving an investigational drug. This was a priority for their organization since only half of the patients had signed an informed consent. After implementation of the pharmacy service, this reached 100% compliance.
· Patients should not experience an adverse reaction to a drug that is predictable and preventable. For example, red man syndrome for vancomycin.
· Patients should receive the correct dose and drug as prescribed.
· Patients should not develop a nosocomial infection from drugs that should be sterile.
· Patients should not receive drugs to which they have a known allergy.
· Outpatients should receive their prescriptions in a timely fashion, e.g. 20 minutes.
· Patients should have doses of drugs individualized when necessary.
· Patients should receive the most effective drug therapy at the least cost.
For each of these goals, there are performance measures including criteria based audits, e.g. review 50 charts for adverse drug reactions.

There are challenges and barriers to implementation of the improvement model such as cost containment pressures, the pharmacist shortage, and weak public expectations of pharmacists. In addition pharmacists may be reactive rather than strategic in their actions, have inadequate skills to manage change, and be selectively hearing what we want to hear, not what needs to be done. However, opportunities also exist because pharmacists can make a difference and can help address public concerns regarding the cost of, access to, and quality of health care.

In December 2000, there was a Human Resources study of the supply and demand for pharmacists. It determined the supply of pharmacists has increased, but demand has grown faster than supply. A shortage of pharmacists with vacancy rates of 6-7% in chain drug stores and 22% in hospitals was recognized. The average time to fill a position was 6 months.

The increase in demand for pharmacists is multi-factorial. More prescription drugs are being used worldwide. There are more practice sites with the growth in the number of chain drug stores and the increase in store hours, eg. 24 hours, 365 days a year. Managed claims require more time to process since there are criteria to adhere to and authorizations to obtain. There is an expansion of pharmacist practice roles and at the same time part time employment is increasing. Finally, in the transition to entry level Pharm D degrees, there were some faculties that had no graduates for some years.

Solutions to the pharmacist shortage include the increased use of technicians, automation and technology to relieve some of the pressures on pharmacist time. Enrollment in Colleges of Pharmacy can be increased. Uniform prescription benefit plans that simplify the adjudication process would ease workload. Workforce mobility would be enhanced with greater licensure reciprocity among jurisdictions including recruiting foreign graduates. Other strategies are found in the AJHP 2001; 58:548, and include, specifically related to the hospital pharmacist shortage, increased salaries especially with comparison to community practice. Some larger centres are hiring pharmacist recruiters that can talk to applicants in a more meaningful way. We also need to create the capacity to improve staff skills and improve orientation and training for new staff. We need to establish relationships with schools of pharmacy, e.g. mentoring and training programs starting early in the students' program. This may include sponsoring some of the costs of students' pharmacy education.

Other solutions involve improving the work environment including spending more time with patients. This may require retraining pharmacists and restructuring positions towards cognitive pharmacy practice. By reassigning technical work e.g. purchasing, inventory, scheduling, and computers, to technicians and by outsourcing medication preparation e.g. IV admixture preparation, pharmacist time will be freed up. One of the difficulties with expanding the technicians' role is that their scope of education and practice is not consistent. There are other models for supportive practices, e.g. dentistry, anaesthesia, labs, where there is control over the profession with significantly higher ratios of technicians to professionals. We need training programs for pharmacists on how to delegate tasks to technicians and how to supervise them e.g. pharmaceutical dispensing labs in conjunction with technicians. Ideally this should be incorporated early in the curriculum.

Technology and the Pharmacist

Technology can be applied to drug preparation, drug distribution (centralized and decentralized), IV drug delivery, computer order entry and bar coding for MARs. Some of the barriers include cost, system compatibility, regulatory limitations, and resistance to the implementation of technology from pharmacists, nurses, and physicians. Drug preparation can be automated using TPN compounding machines, syringe fill devices, robotic admixture systems and outsourcing. Technologies for drug distribution include centralized robots such as the APM® or IDS® and decentralized systems such as Pyxis®, SureMed® or DocuMed® which have application in different areas of patient care. IV Drug delivery technologies such as syringe pumps, PCA devices, implantible devices and infusion control devices can be used.

Physician computer order entry is receiving a lot of attention from groups such as Leapfrog. Models are based on studies at two hospitals that have decision support logic in conjunction with the order entry system. Results showed a positive impact on transcribing errors and transfer of information. Initial steps include development of standardized order protocols that facilitate the automation process. To get the best value from these systems, more complex clinical decision support logic that will provide feedback to physicians is needed.

Bar code application to bedside care has been a long time coming even though it improves documentation accuracy. It can also include clinical decision support such as a wrong patient alert, wrong time alert, and drug allergy/ interaction alert. This technology will also allow assessment of drug administration system performance. There still needs to be an evaluation of bar code standards and how they apply to the individual dose the patient receives.

Outpatient technologies include automated dispensing machines, automated telephone refill systems, point of care patient testing systems for monitoring drug therapy, clinical information systems that provide more information to pharmacists, and electronic prescription systems.

In summary, the use of technology and automation is increasing, and can be an enabler of advanced practice roles.

Leadership Succession Planning

There are fewer middle management positions where staff can learn the skills of the trade. Management is not as appealing to pharmacists as it used to be because the job is not fun any more. Leaders also need new skills they do not learn in pharmacy school such as change management, operations improvement, personnel management, and communications. Most leaders have completed a residency program where they have had the opportunity to be mentored.

Patient Safety

The IOM recommended specific strategies to improve Medication Safety in their "To Err is Human" report. These included:
· Systems oriented approach to medication error reduction.
· Standardize processes in patient care areas - doses, dose timing, dose scales. Reductions in variation will reduce errors.
· Standardize prescription writing/rules.
· Limit the number of different types of common equipment.
· Implement physician order entry.
· Use pharmaceutical software.
· Implement unit dosing.
· Pharmacy supplies high-risk IV medications, eg. antibiotics.
· Written procedures for high-risk drugs, such as those used in the ER, OR, NICU and PICU, e.g. neuromuscular blockers.
· No concentrated medications in patient care areas, e.g. KCl.
· Pharmaceutical decision support with pharmacist review of orders before they are dispensed and administered.
· Pharmacists go on rounds in patient care areas.
· Patient care information available at the point of care.
· Improve patient knowledge about their treatment to provide an additional check on the system.

Pharmacy can respond to the IOM report by:
· Establishing an administrative structure for improving the medication use system that would bring together pharmacists, nurses, prescribers, and risk management staff in an interdisciplinary group under the umbrella of the Pharmacy and Therapeutics committee to address these issues.
· Help create an environment for improvement where there is no fear of discipline and caregivers can discuss changes that will improve patient safety. Medication incident reporting needs to be separate from the performance appraisal system.
· Implement best practices as outlined in many reports. These include voluntary reporting of adverse drug events and near misses, implementing computerized prescriber order entry systems, unit dosing, and not stocking concentrated medications in patient care areas.
· Create performance measurements for the medication use system using surrogate measures such as lab values, the use of antidotes and other drugs used to treat ADRs, and direct measures such as pharmacist interventions, and medication use evaluation studies.
· Test change concepts that have the potential to improve medication use such as standardization/protocols e.g. treatment of hyper/hypokalemia, educational programs, and collaborative practice models e.g. anticoagulant support service.

Seamless Care

The current system is very fragmented with few incentives to create seamless care. It will take a long time to solve the existing problems. There are confidentiality issues as well as freedom of choice/ restraint of trade questions. As technologies such as the Internet, and smart cards evolve, there may be more progress.