Developing Clinical Pharmacy Services and Effective Pharmacy Leadership

1. Developing Clinical Pharmacy Services and Effective Pharmacy Leadership William A. Miller, Pharm.D., MSc, FASHP, FCCP Professor Emeritus, University of Iowa

2. Presentation Objectives At the conclusion of this presentation you will be able to • Critically evaluate the effectiveness of your current practice model • Construct a practice model that focuses on optimizing patient care outcomes and safety • Use new strategies to expand clinical pharmacy services • Consider changes in your leadership and management skills to improve your effectiveness

3. Management and Leadership • Ideally individuals in executive or director positions have both excellent leadership and manager skills • Anyone can be a leader • Leaders set the direction for the organization and influences people to follow that direction. Managers follow the direction for the organization and implement programs, and achieve goals and objectives set by leaders • Leaders do the right thing and managers do things right • Leaders set direction by developing a clear vision and mission, and conducting planning that determines the goals needed to achieve the vision and mission. They motivate or influence people by using various methods: facilitation, coaching, mentoring, directing, delegating, and rewarding

4. Differences Between Managers and Leaders [1] • The manager administers; the leader innovates. • The manager is a copy; the leader is an original. • The manager imitates; the leader originates. • The manager focuses on systems and structure; the leader focuses on people. • The manager relies on control; the leader inspires trust, • The manager has a short-range view; the leader has a long-range perspective. • The manager focuses on the bottom line; the leader has an eye on the horizon. • The manager accepts the status quo; the leader challenges it. • The manager is the classic good soldier; the leader is his or her own person. • The manager does things right; the leader does the right thing.

5. Characteristics of High Performance Leaders • Clear vision • Develop an administrative team with unity of purpose and values • Surround themselves with other individuals who have complimentary skills • Proactive versus reactive: Seek to expand circle of influence (Avoid saying “if only”) • Good communications skills (Respected by able to disarm people and put at ease for communications) • Build relationships with key leaders: administration, medical, nursing, etc. • Value different perspectives: Good listeners • Develop a positive departmental structure: openness, value of every staff member, • Cultivates the “I and we will attitude” • High performance expectations (model and expect of staff)

6. Which of the following is a false statement? • Pharmacy leaders set the direction for the department • Leaders do things right and managers do the right thing • Mangers have a short term view and leaders have a long term view • Pharmacy leaders have a clear vision • Pharmacy leaders build relationships with other hospital leaders

7. Strategic Planning • Mission of the department of pharmacy • Vision for the department of pharmacy • Values of the department of pharmacy • Goals of the department of pharmacy • Short term goals: annual (one to 2 years) • Long term goals: 3 to 5 years • Goals are broad: Establish decentralized pharmacy services • Objectives aimed at achieving goals • Example: Establish decentralized pharmacy services for all critical care services by 6/2011 • Actions plans are detailed steps to achieve a specific objective with dates and accountable person • Actions plans lead to implementation and achievement of goals and objectives

8. What are the barriers to further optimization of pharmacy services? • Perceived value of pharmacists as providers of patient care (“Providers”) • Leadership • Health care and pharmacy practice models • Qualifications and credentialing of pharmacists as patient care providers • Required standard of care: Best practices • Present information technology/automation • Funding of cognitive services

9. Strategies to Achieve Vision • Develop an organizational chart matched to vision • Develop administrative team with shared values • Hire competent staff for all positions • Engage staff in planning and decision making • Elevate qualifications for providers of clinical services: Residency, board certification • Credential and privilege pharmacists: Scope of practice as patient care providers. • Develop a pharmacy practice model matched to the vision • Use automation and technology effectively

10. Strategies to Achieve Vision • Use pharmacy technicians to reduce pharmacist involvement in distributive and other technical duties • Development systems to improve medication-use-systems • Champion improvements for the medication-use-system • Align clinical services with regulatory requirements and quality organizations • Align clinical services with funding opportunities • Align clinical services with institutional plans • Align pharmacy practice model to medical practice model

11. Audience Participation • What strategy are you planning or presently implementation to increase the quality or quantity of clinical pharmacy services provided by your department?

12. What are the goals for clinical pharmacy services? • Assure optimal drug therapy outcomes • Effective drug therapy • Safe drug therapy • Cost-effective drug therapy • Assure pharmaceutical care is coordinated and provided collaboratively with other pharmaceutical care providers • Assure effective relationships with patients that lead to patient involvement, understanding, adherence • Assure efficient and patient focused delivery of care

13. What is the evidence of the value of clinical pharmacy services[2-8] • Abundant number of publications documenting the value of clinical services in inpatient and outpatient settings • Most pharmacists in published studies were full time clinical pharmacists on interdisciplinary teams (i.e., generalists or specialists) and not pharmacy generalists in an integrated system (i.e., performing distributive as well as clinical functions) • Need for research comparing integrated, hybrid and coordinated practice models

14. What is the Evidence for Specialization and Teams • Is specialized medical care better than care provided by generalists? • Is interdisciplinary team care better than care provided by one discipline? • Should pharmacists all have the same KSA or have different KSA? • Should pharmacy teams be multidisciplinary like medical teams? (pharmacy generalists, clinical specialists, compounding specialists, informatics specialists, safety specialists) • Can clinical pharmacy specialists have the same job description as clinical pharmacists?

15. What is the status of clinical pharmacy services in hospitals/health care systems? [9-11] • Variable: Comprehensive to minimal • Comprehensive more likely in medium to large hospitals • Diffusion of ADC for drug dispensing • Diffusion of decentralized pharmacists but variable quality and quantity of clinical services provided. • Adoption and diffusion of clinical pharmacy services has been slow

16. Adopter Categorization Rogers EM. Diffusion of Innovations

17. Diffusion of Innovations Shift the curve to the left B Move up the curve A Rogers EM. Diffusion of Innovations

18. Core and Advanced Clinical Pharmacy Services • Core Clinical Pharmacy Services • Medication profile review to identify and address drug related problems • Target drug monitoring • Provision of drug information as requested • Participation in medical codes • Participation in patient care unit team meetings • Participation in drug policy development • Medication reconciliation as needed • Patient discharge counseling as needed

19. Core and Advanced Clinical Pharmacy Services • Advanced and Specialized Clinical Pharmacy Services • Prospective or concurrent treatment planning through consistent participation on formalized interdisciplinary teams (rounds) • Comprehensive medication therapy management through P&T approved protocols for monitoring drug therapy and changing drug therapy (hospital wide or department/division specific) or collaborative practice agreements • Clinical specialists (usually PGY1 residency and PGY2 in specialized practice areas: Critical Care, Oncology, Transplantation, Cardiology, Infectious Diseases)

20. Health Care Reform • Expansion of health care (Most agree about the benefits of expanding health care coverage) • Reduction in health care costs: (All agree need to reduce costs of health care) • A lot of the public want expanded health care benefits but don’t want to pay for it. • No interest group wants to be negatively impacted

21. Impact of Health Care Reform on Clinical Pharmacy Services • Potential Opportunities • Team based care (Medical Home Model, Accountable Care Organizations) • Continuity/transitions of care/prevention of hospital readmissions/prevention • Medication therapy management services and medication reconciliation • Expanded use of technology and automation to improve safety and efficiency • Implementation of new reimbursement models • Testing of various models to deliver care (comparative effectiveness research) • Need to take advantage of these opportunities as health reform moves forward

22. Impact of Health Care Reform on Clinical Pharmacy Services • Potential threats • Inadequate funding of clinical services (fee for service or portion of funding provided to support patient care or a new reimbursement method) • Impact of cost reductions on funding of clinical services (delayed implementation, reduction in services) • Use of other providers to provide pharmaceutical care because of political and/or economic reasons

23. Which of the following statements is a false statement • Evidence of the value of teams is sufficient • Evidence of the value of clinical pharmacy services is insufficient • The diffusion of clinical pharmacy services, as an innovation, was quite rapid • Inadequate funding of clinical pharmacy services as a part of health care reform is a potential threat to pharmacy • The “Medical Home Model” may provide an opportunity to expand clinical services in ambulatory care settings

24. Pharmacy Practice Models [12-16] • Model • Model is defined as “structural design of something” • Organizational chart reflects the practice model or structure being used for the delivery of pharmacy services • System • A group of interacting, interrelated, or interdependent elements forming a whole • A system for the delivery of pharmacy services reflects the practice model used • Ideal Practice Model • Allows achievement of the desired pharmacy service mission, goals and objectives while adhering to core values

25. Integrated, Coordinated and Hybrid Practice Models • Integrated model • One pharmacist job description • All pharmacists provide distributive and clinical services concurrently • Pharmacists rotate to central and decentralized practice areas

26. Integrated, Coordinated and Hybrid Practice Models • Hybrid model • Central and decentralized pharmacist roles under one job description: Selected central pharmacists assigned to decentralized role on a rotating basis • Decentralized pharmacists may only focus on target monitoring and other clinical services, have concurrent distributive responsibilities and rotate to central area to staff

27. Integrated, Coordinated and Hybrid Practice Models • Coordinated model • Multiple job descriptions with different roles and responsibilities: Centralize pharmacist, decentralized or clinical pharmacist, clinical specialist • Pharmacists supportive of various roles, capable (not proficient) to perform different roles, and care is coordinated (team approach) to achieve common goals

28. Basis for Pharmacy Practice Models Used Today • Beliefs of pharmacy leadership which are based upon experiences, training, values and opinions of thought leaders and organizations • Number and quality of staff • Use of information technology and automation • Nursing, physician and hospital administration beliefs and support

29. Basis for Pharmacy Practice Models Used Today • Consultant recommendations • Politics • Model development • Evolve by adding clinical to distributive services • Rarely redesign of existing model but tweek of existing • Usually driven by beliefs and subjective opinions • Lack of evidence-based research on effectiveness of practice models and metrics for staffing to make practice model design decision making more objective

30. Observations About Today’s Pharmacy Directors/Leaders • Similar goals for pharmacy services: • Safe drug distribution and medication use system • Quality clinical services • Difference in service emphasis • Safe drug distribution system maybe emphasized or viewed as being more important than influence on the quality of pharmaceutical care • Are dispensing errors more significant than prescribing errors? • As pharmacy clinicians with good leadership and management skills are appointed pharmacy directors will clinical services be emphasized?

31. Pharmacy Directors/Leaders • Different definitions of quality clinical services • Target drug monitoring and cost reductions as outcomes (Often see in integrated models) • Pharmacists on interdisciplinary teams share responsibility for drug therapy outcomes with physicians and other providers (Often see with coordinated models) • Different assessment of the level of clinical services actually being provided by the department

32. Director Pharmacists Central staffing rotation Decentralized staffing rotation Model 1(Integrated): Small community hospital

33. Director Central Pharmacists Select Central Pharmacists: Targeted Monitoring and MTM Model 2(Hybrid): Small community hospital

34. Director Assistant Director Central Pharmacy Coordinator Clinical Services Assistant Director Outpatient Services Central Pharmacists Decentralized Pharmacists Clinical Specialists Outpatient Dispensing Pharmacists Clinical Specialists Model 3 (Coordinated): Medium Sized Community Hospital

35. Director Assistant Director Inpatient Services Assistant Director Outpatient Services Centralized Services/Lead Decentralized Services/Lead Centralized Services/Lead Central Pharmacists Clinical Pharmacists Outpatient Pharmacists Clinical Specialists Clinical Specialists Model 4 (Coordinated): Medium Sized Community Hospital

36. Model 5 (Coordinated) Large University or Community Hospital

37. CHIEF PHARMACY OFFICER Director Transplantation Services Director Medical and Surgery Services Director Oncology Services Director Pediatric Services Director Psychiatry Services Director Outpatient Services Director Central Inpatient Pharmacy Services Team Leaders for Clinical Pharmacists and Specialists Team Leaders for Clinical Pharmacists and Specialists Team Leaders for Clinical Pharmacists and Specialists Team Leaders for Clinical Pharmacists and Specialists Team Leaders for Clinical Pharmacists and Specialists Further organization Central Pharmacists Model 5 (Coordinated): Large University or Community Health System

38. Model 7 (Coordinated) Large Health Care System

39. Advantages and Disadvantages of Practice Models • Advantages of Integrated Practice Models • Recruitment of pharmacists to provide clinical services easier because larger applicant pool • Scheduling of pharmacists easier • Staff morale maybe enhanced because all pharmacists have the same responsibilities and status • Greater percent of patients may receive core clinical services • Disadvantages of Integrated Practice Models • Minimal level of clinical services may result (e.g., new order review, target monitoring, drug information) • Patient populations needing advanced patient care services maynot receive sufficient services • Pharmacists may not become essential members of interdisciplinary teams and as a result miss opportunities to improve patient outcomes

40. Advantages and Disadvantages of Current Practice Models • Advantages of Coordinated Practice Models • Pharmacists on interdisciplinary teams provide advanced/specialized clinical services as essential team members • Clinical services provided to interdisciplinary teams better (specialized knowledge, skills and abilities; greater awareness of pertinent patient safety issues for the specific patient population, repetition/proficiency) • Better use of pharmacist knowledge, skills and abilities (PGY1 and PGY2 residency training) leading to improved employee satisfaction • Disadvantages of Coordinated Practice Models • Creates scheduling problems • Replacement of pharmacists more difficult • Silos may develop and impair effectiveness of internal pharmacy team while enhancing interdisciplinary teams

41. Ideal Practice Model Requirements • Core clinical services should be provided to all patients. • Specialized/advanced clinical services must be available to all patients requiring these services • Clinical services should be consistently provided • The model for the overall delivery of pharmacy services must be efficient, effective and coordinated (team approach). • The model must fit the system used by the hospital and/or medical staff for delivering patient care. • Providers of all pharmacy services must be competent. • An appropriate mix of staff with needed KSA must be employed • The model must result in a safe medication use system. • The model must result in pharmacists being essential patient care providers and members of formalized interdisciplinary teams. • Pharmacy residents must be included in the model as appropriate • The model must result in a positive department culture, and high morale and retention rates.

42. Audience Participation • Briefly describe your current practice model and then answer the following questions. • How have you assessed the effectiveness of your current practice model? • How are you planning to change your practice model to further optimize patient care outcomes and safety?

43. Applying Principles of Systems to Develop a Pharmacy Practice Model • Containment (Subsystems): Practice models used by physicians and nurses need to be considered in deciding on pharmacy practice model • Teaching hospitals with formalized interdisciplinary teams and house staff different than community hospital model with private physicians and no formalized teams • Ripple Effect of Change: • Changing the type of pharmacists hired for decentralized pharmacy positions affects outcomes of the whole system

44. Applying Principles of Systems to Develop a Pharmacy Practice Model • Synergy: If all parts of the practice model are working well and together, synergy is achieved (optimum drug distribution, patient care, drug policy and medication use systems)

45. Applying Principles of Systems to the Ideal Practice Model • Rule of the weakest link: • Hiring a director who views pharmacy as a material management versus a clinical department affects mission and vision for patient care services to be provided by pharmacists • Placing unqualified pharmacists in clinical roles impacts overall system (patient care outcomes diminished) • Assigning a critical care pharmacist 50 patients or a decentralized pharmacist 150 patients to provide distributive and clinical services affects type and amount of cognitive services provided • Rotating pharmacists to different areas (central, patient care) affects ability of pharmacists to become essential members of interdisciplinary teams

46. Factors Influencing Selection of the Best Pharmacy Practice Model • Different Perspectives on How to Design the Best Pharmacy Practice Model to Optimize Patient Outcomes • Patient care effectiveness • Patient care safety • Efficiency of care (quality/costs) • Balance of outcomes

47. Factors Influencing Selection of the Best Pharmacy Practice Model • Cognitive services to be provided • Core clinical services • Specialized/advanced clinical services • Prospective involvement in establishing patient treatment plans versus routine monitoring • Collaborative drug and disease state management • Core and specialized/advanced services will need to change for pharmacy to continue to add value to health care • Specialized/advanced services today will become future core services • Specialized/advanced services in the future will be affectedby advances in health care, new drugs, pharmacogenomics, advanced decision support systems

48. Model Effect on Cognitive Services Provided Cognitive Domain Affective Domain Evaluation  Synthesis  Analysis  Application  Comprehension  Knowledge Characterization  Organization  Valuing  Responding  Receiving

49. Practice Model Effect on the Level of Cognitive Services Provided • Reviewing routine orders: Low to medium • Target drug monitoring: Low to medium • Managing anticoagulation: Low to medium • Developing best practice guidelines, protocols: High • Determining best treatment plan for a critical care patient with multiple disease states: High

50. Factors Influencing Selection of the Best Practice Model • Patient care acuity and complexity • Quaternary and tertiary care versus secondary care • Type of patient care unit: Intensive care and emergency department, step down or intermediate care, general patient care • Size of the inpatient or ambulatory patient population • Size affects overall staff resources needed to provide comprehensive pharmacy services: inadequate staffing compromises level of clinical services.