Pharmacy Leadership Challenges
Philip J. Schneider
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.
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.
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.
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
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
· Efficiency - avoid waste, some statistics say 50% of
care is wasted.
· Equitable - quality of health care does not vary by location,
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
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
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
Ischemic heart disease
Gall bladder disease
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.
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
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.
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
· 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
· 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
· 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
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.
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.
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.
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.
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.
and the Pharmacist
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
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.
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
the use of technology and automation is increasing, and can be
an enabler of advanced practice roles.
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.
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
· 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.
· 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.
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
· 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
· 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.
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.