broke out to consider five questions related to Pharmacy Leadership
Challenges. The summaries from these groups is presented below.
1. What are
the aims (aspects of care) for Canadian hospital pharmacists?
We need aims and objectives for pharmacists and their professional
organizations. These may include advancing professional practice,
spending more time with patients, enhancing competence, and improving
practice through automation and the use of technicians. Patients
expect to be healthy, that the health care system is safe, and
that treatment is effective, timely, and cost-effective. This
is a double edged sword since if you don't move forward, staff
will not feel challenged, but you cannot keep asking more of people
in a tight fiscal environment. There has to be a balance between
both of these and we need to determine what we don't need to do
any more or what can be re-engineered. Staff have to contribute
to the strategic direction of the department and hospital rather
than just doing what they want to do.
aims for the profession to focus on (measurement indicators available
in the Canadian Hospital Pharmacy Report):
- Increased proportion of pharmacist time spent on direct patient
- Decreased pharmacist vacancy rate; Decreased time to fill vacancies.
- Increased delegation of technical tasks to pharmacy technicians
and other support staff.
- Increased utilization of automation - all aspects of the care
delivery system; improve the safety and efficiency of hospital
- All patients discharged on thrombolytic therapy should be given
appropriate counseling by a pharmacist.
- All patients to receive appropriate medication discharge instructions
by a pharmacist (hospital or community).
- All patients to receive a medication history by a pharmacist
within 48 hours of admission.
- Patients receiving aminoglycoside antibiotics to have doses
adjusted according to body weight and renal function.
- Pharmacy dispenses the correct drug, dose and administration
- All patients receive pharmacy services shown to improve quality
and cost effectiveness of therapy.
2. What can
technicians do that pharmacists currently do?
The Canadian Hospital Pharmacy Report reported fewer vacancies
for technicians than pharmacists and that our ratio of pharmacists
to technicians is not particularly high. Most advanced practices
have ratios of 3-4:1 for technical to professional staff. We need
to realize we are all at different places in this journey, but
it is a destination we all need to head towards. Technicians can
be used for management functions, coordinating the work of other
technicians, and training of other technicians. Information systems
and maintenance of automation can easily be delegated to technicians
(despite a natural tendency of pharmacists to gravitate to technology).
This is in addition to the more traditional roles for technicians
in dispensing and distribution and purchasing and inventory control.
We also need to determine how to proceed with legislation, training
and certification. We need the support of pharmacists, information
systems, adequate technician staffing and stability. Successful
models need to be published in order to help others.
to Delegate what
Pharmaceutical care Technicians, IT Data collection, maintain
DUR and DUE Technicians or students Data gathering
Discharge counseling Technicians or clerks Material preparation,
calendars, insurance coverage information
TPN monitoring Nutritionists Data gathering, recommendations
Patient teaching Nurses Teaching using prepared materials
Investigational studies Technicians Dispensing, logs, statistics,
inventory, returns, billing, inservices to other technicians
Special access drugs Technicians Purchasing, documentation, inventory
Drug information Clerks Literature searches, ordering journals,
data base coding, copying, gathering references
Information technology Technicians Data base work, reports
Drug distribution Technicians See separate list; pharmacists still
need to design the systems and the quality assurance mechanisms,
Materials Management Technicians, clerks, porters Purchasing,
inventory control, contract processing
Other Technicians or clerks Workload measurement, scheduling,
financial month end, telephones
activity Pharmacist Check Tech to Do Tech to Check
Order entry(Or Clinician Order entry also) X X (practicality?)
Traditional inpatient prescriptions X X
First dose dispensing X X
Unit Dose cart fills X X
Centralized unit dose automation fill X X
Decentralized dispensing automation fill X X
Night cupboard fill X Not needed
Prepackaging X X
CIVA program X X
Chemotherapy X X (Yes but?)
TPN X X
Leave of absence Rx X X
Retail prescriptions X X
Emergency drug boxes X X
Wardstock X (or assistants) Not needed
Narcotics X RN check
Master Worksheets X (do and check)
3. What can
be done to address workforce issues in Canadian hospital pharmacy?
We need to do less work so fewer pharmacists are required. There
has to be visioning and enthusiasm because we need to know where
we are going over the next few years. Some work like medication
histories and discharge planning are labour intensive and unpredictable
work. Pharmacists can target certain patients and at the same
time help nurses develop teaching materials for most patients.
We also need to make work more attractive and give positive reinforcement
to staff. Student liaison needs to be a priority. In addition
to focusing on recruitment, and retention, we need to re-engineer.
- Market the
hospital pharmacy profession: newspaper articles and media coverage;
Mentorship at the beginning of the BScPhm program; talk to public
and patient groups; increased awareness and expectations from
patients; promote pharmacy within your organization. Pharmacy
organizations need to be involved at a high level, but we can
also do this locally in our own workplace.
- Work on recruitment and retention: student loans; increase the
salary of pharmacy residents; look at family and spouse issues
for staff; examine the organization of services in the department
e.g. scheduling and vacation time, balancing part-time positions;
have pharmacy students exposed to hospital practice and hired
earlier; offer a good orientation; career plan for pharmacists
e.g. where they want to go clinically; CAPSI book lists the questions
that students should ask when they go for interviews; signing
- Rethink teaching: The money for teaching is less than that available
for medicine; can we do things differently; start teaching earlier;
mentorship; technician teaching to ensure they have the skills
- Communicate: to preserve the team spirit both as a department
and as an interdisciplinary team; next Canadian Hospital Pharmacy
Report could have a section on job satisfaction that would go
to all pharmacists (or CSHP could do this).
- Have control over the demand for services: need to understand
the demand for services and control expectations; need to focus
on the most relevant outcomes.
- Create a more mature role profile for pharmacists: the profession
has evolved and we need a model for pharmacists to follow which
will improve job satisfaction; mentorship and education for the
continuum of clinical skills up to complete pharmaceutical care.
- Improve organizational and management skills.
4. What is
a good strategic plan for introducing automation and technology?
Technology is the enabler, not the solution. Implementation is
difficult and time consuming and IT can create new kinds of problems.
Before implementing we need to map our processes and define best
practices, for example computer order entry allows us to check
dose ranges more easily, but that process should already be in
place. Staff resistance to technology should not be underestimated.
Automation may allow for reduction of FTEs which may help solve
Plans for Automation and Technology
- Many different types of technology improvement can be investigated.
Your current situation to will determine which areas to focus
on first. The Pharmacy strategic plans need to tie into the hospital's
strategic and operational plans.
- Strategic focus areas for a hospital could be patient outcomes,
quality and safety, recruitment and retention, technology, adoption
of standards, appropriate use of interventions, streamlining of
activities and efficiency, or competition in the marketplace.
- This is not a "one size fits all" process and it includes
long term plans with annual presentations and ongoing communication.
- Stakeholders need to be identified and can include pharmacy
staff, nurses, doctors, Pharmacy and Therapeutics committee, administration,
patients, IT services, risk management, provincial and other regulatory
bodies, and insurers and employers.
- The stakeholders should be involved early in order to feel part
of the process. They need to have input into developing solutions.
We need to listen to what they are telling us.
- Ask stakeholders what they want to get out of the process of
change, e.g. quality, patient safety, efficiency. Some expectations
may not be realistic so you need to ensure they understand what
you are measuring, e.g. medication errors may go up with a new
system, since voluntary reporting is inaccurate.
- May need different strategies depending on the group, current
system issues, and sentinel events that may drive change. Some
members of the group may be uncomfortable with the technology
you are recommending which can be a barrier.
- Need to be careful in discussions of #FTE saved with a technology.
It is better to frame the project in terms of freeing pharmacists,
nurses, etc. from technical tasks to allow for a more clinical
focus. The number of lives saved, using information from the Institute
for Safe Medication Practices can also be used.
Interests and Expectations
Nurses - increased efficiency, accessibility and turn-around times-
focus on actual problems and use a patient-centred approach- interested
in quality and reduction of potential errors- want increased input
and education- need to address staffing shortages and be sensitive
to their history of staff layoffs- may be hard to involve nursing
due to shortages and changing structures in organizations- don't
want to be guinea pigs so be sure to share success stories from
Physicians - in the past, were often not aware of medication errors
and the issues around them- they may have competing priorities,
e.g. patient waiting times and may be more interested in saving
time than saving money- need specific examples of what patient
safety means and use studies to support an "evidence based"
approach to improving care; look at potential impact on liability
insurance and costs- need to determine the impact of change on
physicians- one tactic is to have strong physician advocates that
can use peer to peer communication to reach physicians; in some
hospitals this is a paid position- other forums to access physicians
include Pharmacy and Therapeutics, Medical Advisory and Quality
Pharmacy Staff and their Unions - need to have a vision and build
on it- particularly important to have their early involvement
including the union if applicable- need to address the fear of
job loss- stress job changes and new roles that increase job satisfaction
and responsibilities- need management support for re-engineering
including training and continuing education as part of the implementation
process- look at future volumes and workload in planning- quality
patient care and enhanced clinical roles are important
Administration - need to create a capital business plan including
the impact on operating costs- relate solution to problems that
are relevant to them, e.g. recruitment/retention, effective use
of current skilled staff, increases in quality, increased profile
for the hospital- need to think about increasing awareness of
technology and its' appeal through sharing publications, national
or association statements- look at potential Foundation funding
Patients - advance their awareness re: the impact of technology
on the quality of their care- from an ASHP survey, patients' #1
fear is that they will experience a medication error while in
hospital- take the opportunity to link the project to addressing
their concerns- patients can be strong drivers for change as their
5. What can
be done to improve medication use safety?
This is the hottest topic in pharmacy today and shifts the emphasis
from the drug budget. Medication use safety resonates with consumers,
public policy makers, caregivers and administrators. It validates
traditional pharmacist roles e.g. unit dose, CIVA, clinical services.
It also justifies technology and automation.
- unit dose; IT; help ease strain of shortages.
- Need to promote unit dosing as the system of choice.
- IT can be key strategic partners since pharmacy staff are good
with computers and have successful implementations.
- More involvement in research and design of protocols and reporting
of significant events, post-marketing surveillance.
- Role of P&T committee.
- Reporting, analyzing, identifying trends in medication errors
will encourage physician involvement.
- Disclosure policy re: medication errors to patients.
- Evidence-based decision making, standardization of protocols
and guidelines; standardized dose times - use a collaborative
- Need an organization-wide initiative regarding medication use
safety with pharmacy taking a leadership role.
- Pharmacists need to be in patient care areas.
- Drug information services to professionals and patients one-to-one.
- Pharmacy in-services and communications to professionals and
patients regarding new drugs, protocols; use of web sites and
- Delegation to technicians and support staff allowing more time
in direct patient care.
- Multi-disciplinary program approach with pharmacist prescribing
as per protocol; ability to order lab tests.
- Physician order entry.
- Bar coding.
- Environment - reduce interruptions - both for pharmacy department
and on patient care areas.
- Communicate and share across various institutions re: sentinel
events and errors, e.g. vincristine intra-thecal.
- Seamless care - transfer of care to community pharmacy; use
of auto-sub policies; profile information to the patient.
- Pharmacists more involved in discharge planning.
- Involve patients in expected outcomes of therapy.
- Pharmacists involved in medication histories, MARs and counselling.