A Global Strategic Plan for Hospital Pharmacy

Practice

2

• Brief introduction to FIP, the International Pharmaceutical Federation

• Describe the FIP Global Survey of Hospital Pharmacy Practice

• Describe the FIP Global Conference on the Future of Hospital Pharmacy

• The Basel Statements on the Future of Hospital Pharmacy

Overview

3

• Comprised of 120 member organizations in 82 countries• In total, represents 2 million pharmacists, world-wide• Over 4000 individual members• Headquarters, The Hague, The Netherlands

• Off-site office in Geneva, Switzerland• Relatively small staff (12)• FIP Mission Statement:

• “To improve global health by advancing pharmacy practice and science to enable better discovery, development, access to and safe use of appropriate, cost-effective, quality medicines worldwide.”

International Pharmaceutical Federation (FIP)

4

Structure of FIP

5

• Bureau, the FIP board of directors– Chair, FIP President, Kamal Midha (Canada)

• Executive Committee– President, Scientific Secretary (Vinod Shah, India) and Professional

Secretary (Henri Manasse, USA)

• General Secretary, CEO of FIP– Ton Hoek (The Netherlands)

• Board of Pharmaceutical Science (BPS)– Chair, Mitsuru Hashida (Japan)

• Board of Pharmaceutical Practice (BPP)– Chair, Phil Schneider (USA)– 9 Sections, including Hospital Pharmacy Section (HPS)– Young Pharmacists Group

Summary of Structure of FIP

6

• FIP serves as liaison between pharmacy and other NGOs• In ‘official relations’ with WHO• In ‘working relations’ with UNESCO

• Recent achievements• WHO UNESCO FIP: Global Tripartite Education Action

Plan 2008 – 2010• FIP Collaborating Center for Pharmacy and Health,

School of Pharmacy, University of London

FIP Global Representation of Pharmacy

7

• Recent achievements• A Core Competency Framework for International

Health Consultants (publication)

• BE AWARE: Helping to Fight Counterfeit Medicines, Keeping Patients Safer (publication)

FIP Global Representation of Pharmacy

8

• WHO International Medical Products Anti-Counterfeiting Taskforce (IMPACT)

• Global Network of Pharmacists Against Tobacco• International Alliance for Patient Safety• Good Pharmacy Practice Guidelines and implementation

initiatives• Annual Congress

• 2008, Basel, Switzerland• 2009, Istanbul, Turkey• 2010, Lisbon, Portugal

• Each sections within BPP has active agenda, programming, etc.

Current FIP Activities

9

• FIP Board of Pharmaceutical Practice Special Project

• Support from Cardinal Health also acknowledged• Objectives

– Conduct an exhaustive survey of hospital pharmacy practice describing and measuring the breadth and scope of hospital pharmacy practice worldwide

– Establish a global comparative benchmark for hospital pharmacy practices

– Provide background information for the Global Conference and future HPS programming

FIP Global Survey of Hospital Pharmacy Practice

10

• Survey methods developed in collaboration with Global Conference Steering Committee and HPS officers

• Drew from regional, national and international surveys from Europe (EAHP), UK, USA (ASHP) and Australia

• Sample frame was national respondents from every United Nations-member country– Sought broadest representation in sample, with understanding that

depth of response would be lacking

• Waiver of approval granted by Human Subjects Committee at University of Wisconsin – Madison, USA

• Principal Investigators, Lee Vermeulen and Fred Doloresco, University of Wisconsin – Madison and UW Hospital and Clinics

Methods

11

• Draft instrument developed and reviewed extensively– Questions drawn from previous surveys, Joint Commission

International accreditation standards and other sources– Definitions of terms developed and included with survey– Designed to inform all 6 Global Conference working group themes

• Instrument pilot tested by respondents who were native speakers of English, French, Spanish, and Mandarin

• Final instrument included 75 questions examining scope and breadth of hospital pharmacy practice – Survey instrument translated from English to French and Spanish

Methods, continued

12

• Survey evaluated aspects of practice in 2 dimensions • Scope of practice

– Activity is not in the scope of hospital pharmacy practice in my country– This activity is in the scope of hospital pharmacy practice in my country

but is not a requirement– This is within the scope of pharmacy and is a legal/ regulatory

requirement in my country

• Breadth of practice; how common is the practice? – <3% (very few) of hospitals – 3 – 40% (few) of hospitals– 41 – 60% (some) of hospitals– 61 – 97% (most) of hospitals– >97% (nearly all) of hospitals

Methods, continued

13

• Respondents were recruited to complete the survey– FIP member organizations initially– HPS members– Widespread recruitment effort with support of EAHP and many

other organizations and individuals

• Respondents agreeing to participate in survey were sent instrument for completion

• Recruitment and response collection occured from July 2007 to April 2008

• Analysis included comparisons of responses by geographic region, WHO region and level of economic development (HDI)

Methods, continued

14

• Responses received from 85 of 192 UN-member countries (44%)– Responses received from countries representing 5.4

billion people (83% of global population)

• Wide range of national characteristics included in respondent sample– Approximately 1/3 of countries from each of the World

Health Organization regions– Range of population size, from 40,000 to 1.3 billion– Approximately 1/3 of countries from each Human

Development Index classification

Results

15

• Czech Republic• Democratic Republic of the Congo• Denmark• Ecuador• Eritrea• Estonia• Ethiopia• Finland• France• Germany• Ghana• Greece• Guyana• India• Indonesia• Iran (Islamic Republic of)• Iraq

Results - Respondent Nations

• Algeria• Argentina• Australia• Austria• Bahamas• Belgium• Bosnia and Herzegovina• Brazil• Brunei Darussalam• Canada• Chad• China• China-Taiwan• Costa Rica• Côte d'Ivoire• Croatia

16

• Pakistan• Paraguay• Peru• Philippines• Poland• Portugal• Qatar• Republic of Korea• Romania• Russian Federation• Rwanda• Saint Kitts and Nevis• Serbia • Sierra Leone• Singapore• Slovakia• Slovenia

Results - Respondent Nations

• Ireland• Japan• Kenya• Latvia• Lebanon• Lesotho• Luxembourg• Madagascar• Malta• Mexico• Namibia• Nepal• Netherlands• New Zealand• Nigeria• Norway

17

• United Republic of Tanzania• United States of America• Uruguay• Venezuela (Bolivarian Republic of)• Viet Nam

Results - Respondent Nations

• South Africa• Spain• Sudan• Suriname• Sweden• Switzerland• Thailand• The former Yugoslav Republic of

Macedonia• Timor-Leste• Trinidad and Tobago• Turkey• Uganda• United Arab Emirates• United Kingdom of Great Britain and

Northern Ireland

18

Results: Source of Response Information

121917

56

6372

6567

2821

0

10

20

30

40

50

60

70

80

Personal Impression Other Experts Sub-survey Unpublished Survey Published Survey

Nu

mb

er o

f C

ou

ntr

ies

Used

Not Used

19

• Pharmacist practice model used in hospitals in respondent nations

Results: Practice Model

13.4%11.1%

41.2%38.3%

0%

10%

20%

30%

40%

50%

Staff pharmacists controlmedication use

Staff pharmacists - partialcontrol

Services hired out -partial control

No pharmacists

20

• Proportion of the nation’s total (pharmacy and non-pharmacy) healthcare budget spent on HIV care

Results: Spending on HIV Spending

48

612

52

0

10

20

30

40

50

60

<10% 10 - 20% 21 - 33% 34 - 50% >50%

% of Total Healthcare Budget

Nu

mb

er o

f C

ou

ntr

ies

21

• Proportion of the nation’s total healthcare budget spent on tuberculosis care

Results: Spending on Tuberculosis

17816

51

0

10

20

30

40

50

60

<10% 10 - 20% 21 - 33% 34 - 50% >50%

% of Total Healthcare Budget

Nu

mb

er o

f C

ou

ntr

ies

22

• Proportion of the nation’s total healthcare budget spent on malaria care

Results: Spending on Malaria

4765

61

0

10

20

30

40

50

60

70

<10% 10 - 20% 21 - 33% 34 - 50% >50%

% of Total Healthcare Budget

Nu

mb

er

of

Co

un

trie

s

23

• There are current vacancies that cannot be filled with qualified pharmacists due to a lack of qualified individuals in my country.

Vacancies

11

5

6

10

5

2

15

16

1

4

7

2

0

5

10

15

20

25

30

35

40

45

50

Yes No

Nu

mb

er o

f C

ou

ntr

ies

AFRO AMRO EMRO EURO SEARO WPRO

Results: Pharmacist Vacancies

24

• Please describe the percentage of female pharmacists in hospitals in your country.

Female RPh %

3 3 4 2 4

15

10

1

3

3

3

28

11

1

2

3

7

0

10

20

30

40

50

60

<3% 3-25% 26-40% 41-60% >60%

Nu

mb

er o

f C

ou

ntr

ies

AFRO AMRO EMRO EURO SEARO WPRO

Results: Gender Mix of Pharmacists

25

• The pharmacy department includes technical staff in addition to pharmacists. – The use of technicians to augment the pharmacy workforce is

widespread.

Techs - Breadth

2 3 473

1

3

9

1

1

1

4

1

9

21

1

1

2

1

1

2

2

1

4

0

5

10

15

20

25

30

35

40

45

50

<3% 3-40% 41-60% 61-97% >97%

Nu

mb

er o

f C

ou

ntr

ies

AFRO AMRO EMRO EURO SEARO WPRO

Results: Technician Workforce

26

• With the exception of limited, temporary medicine shortages, hospitals are able to easily obtain medications that are on the formulary or essential medicines list.

– Increasing HDI category correlates with an increased ability to obtain medications– AFRO and EMRO nations reported difficulties in obtaining medications

Able to obtain meds - Breadth

1 36

37

23

6

6

9

2

4

1

2

0

10

20

30

40

50

60

<3% 3-40% 41-60% 61-97% >97%

Nu

mb

er

of

Co

un

trie

s

High Medium Low

Results: Ability to Obtain Medicines

27

• Hospitals distribute the majority of medicines to patients in the hospital as unit doses.

– A high proportion of low HDI nations require and have implemented unit dose dispensing

– A third of low HDI nations report using unit dose dispensing in >97% of hospitals

Unit Dose - Scope

10

32

5

6

14

5

1

4

4

0

10

20

30

40

50

60

Not in scope In scope, not required Required

Nu

mb

er o

f C

ou

ntr

ies

High Medium Low

Results: Unit Dose Dispensing

28

• Pharmacists in hospitals have access to patient files (such as the medical chart or record).

– Little variation across HDI category– Similar results for population and WHO region

Chart - Breadth

910 10

6

12

85

2

5

6

4

1

1

1

1

0

5

10

15

20

25

<3% 3-40% 41-60% 61-97% >97%

Nu

mb

er o

f C

ou

ntr

ies

High Medium Low

Results: Access to Medical Records

29

• Pharmacists in hospitals have access to a medical library with medicine references while they are working.

– Pharmacists in a majority of hospitals in high HDI score nations, but not in medium or low HDI score nations, have access to medical libraries or medicine references

Library - Breadth

3 3

6

14

21

8

5

6

4

2

63

0

5

10

15

20

25

<3% 3-40% 41-60% 61-97% >97%

Nu

mb

er o

f C

ou

ntr

ies

High Medium Low

Results: Medical Libraries

30

• Pharmacists in hospitals are able to prescribe only under certain circumstances (such as under an agreement with a doctor).– Pharmacist prescribing (with or without an agreement with a

doctor) is not employed in a majority of hospitals

RPh Dependent Prescribing - Breadth

31

4 3 4 2

23

11

1

3

1 22

0

10

20

30

40

50

60

<3% 3-40% 41-60% 61-97% >97%

Nu

mb

er o

f C

ou

ntr

ies

High Medium Low

Results: Pharmacist Prescribing

31

• Difficult for any one respondent to reflect upon the nature of pharmacy practice in an entire country– Future HPS should include national sub-samples for

more accurate representation of practice patterns

• Definitions that we all sometimes take for granted are often not consistent from country to country (not simply a language issue!)

Survey Limitations

32

• Targeted survey results will be used to inform discussion of consensus statements during Global Conference

• Results will provide guidance to HPS leadership in developing future programming for Section sessions in years to come

• Full technical report to be made available and manuscript will be part of Global Conference proceedings

• Istanbul Congress, 2009, session to be held to identify future plans for more detailed survey efforts on targeted aspects of hospital pharmacy practice, and to monitor trends in practice development over time

Next Steps for the Global Survey

33

globalhosp@fip.orgwww.fip.org/globalhosp

34

• In December 2005 international leaders in hospital pharmacy met in New Orleans at the ASHP Midyear Clinical Meeting

• Common concerns were observed, common global standard of practice was missing

• The FIP Hospital Pharmacy Section was chosen as host for global consensus conference

• A steering committee was formed– Several subcommittees started to work

• Meeting took place 30 – 31 August 2008 in Basel

Background: FIP Global Conference on the Future of

Hospital Pharmacy

35

• To build a shared vision among hospital pharmacy opinion leaders around the world about the preferred future of hospital pharmacy practice.

• To identify strategic goals for global advancement of hospital pharmacy that are relevant to the needs of each participating country, and to identify opportunities for global cooperation that will allow every country to achieve their goals for hospital pharmacy.

• To develop consensus statements on how to best prioritize practice advancements and offer guidance on the development of tools, timelines and tactics for achieving those advancements.

Objectives: FIP Global Conference on the Future of Hospital

Pharmacy

36

• Honorary Conference Co-Chairs– Jacqueline Surugue (France), EAHP– Henri Manasse (USA), ASHP

• Steering Committee– Lee Vermeulen (USA), Chair– William A. Zellmer (USA), Vice Chair– Satu Siiskonen (The Netherlands), Conference staff– Toby Clark (USA), Chair, Finance Subcommittee– Stephen Curtis (UK)– Andy Gray (South Africa), HPS President, Chair, Delegate Selection Subcommittee– Stefan Mühlebach (Switzerland)– Philip J. Schneider (USA), ex officio BPP representative– Thomas S. Thielke (USA)– Dick Tromp (The Netherlands ), ex officio BPP representative– Arnold G. Vulto (The Netherlands), Chair, Programming Subcommittee– Eduardo Savio (Uruguay)– Zhu Zhu (China)

Global Conference Leadership

37

• Six facilitators were recruited for one of six themes, each focused on a different components of hospital pharmacy practice

– Literature reviews written– Develop draft consensus statements– Lead working groups via internet and “live” at the conference

• Facilitator assignments:– Procurement of medicines (Eva Ombaka, Kenya, Africa)– Prescribing of medicines (Lisa Nissen, Brisbane, Australia)– Preparation and distribution of medicines(Ryo Oishi, Japan)– Administration of medicines (Rita Shane, Los Angeles, USA)– Monitoring outcomes (David Cousins, UK, Europe)– Human resources and training (Tana Wujili, FIP)

Global Conference Structure and Faculty

38

• Fundraising and scholarships• Recruitment and selection of official representatives (delegates)• Initial development of literature reviews and draft consensus statements• Preliminary consensus development amongst working groups began

Summer 2008• Conference occurred 30th - 31st August, 2008, Basel Switzerland

– Nearly 350 delegates (22 scholarship recipients) attended from over 90 countries

– Over 80 countries were represented by official representatives• Plenary session• Working group sessions• Editing of statements• Voting process for consensus statements

Global Conference Process

39

• As each consensus statement is read, official representatives voted using audience response system

• The voting scale used as follows:

A = I strongly agree with the statement

B = I agree with the statement

C = I disagree with the statement

D = I strongly disagree with the statement

Voting Scale

40

1. A consensus statement was read by the facilitator for the group that developed the statement, and if necessary, brief comments were also made

2. Official representatives were be asked to vote on the statement and the results of the vote were shown

3. If a clear consensus was reached (simple majority of votes are A (“strongly agree”) or B (agree), the statement was accepted

Voting Process

41

• A total of 74 consensus statements were developed• Overarching statements• Statements from each working group

• A total of 82 countries cast a vote on at least 1 statement• Across all statements, an average of 64.1 votes per

statement were cast• All statements were approved with consensus• Across all statements, the average level of consensus

(proportion of votes cast as “strongly agree” or “agree”) was 97.5%

• Of 5,259 votes cast• 3,821 (62.8%) were “strongly agree”• 1,314 (21.7%) were “agree”• Only 111 were “disagree” and 22 were “strongly disagree”

• A total of 26 statements (35%) had 100% consensus (“strongly agree” or “agree”)

Results!

42

• The definition of “hospital pharmacist” needs additional development. Current definitions vary worldwide, based on traditions and national regulations and ambitions, but in general:

• Pharmacist working in a hospital;• Specialized training, generally post-graduate (including residency);

• The overarching goal of hospital pharmacists is to optimise patient outcomes through the judicious, safe, efficacious, appropriate and cost effective use of medicines.

• Hospital pharmacists should take responsibility for all medicine logistics in hospitals.

• Hospital pharmacists should provide orientation and education to nurses, physicians and other hospital staff regarding medication use, using best practice recommendations.

Themes in Basel Statements

43

• Feedback forms provided to gather additional written comments on any consensus statements, additional statements and final editing underway now (17th September 2008)

• Draft Basel Statements at www.fip.org/globalhosp• Full proceedings to be published in American Journal

of Health-System Pharmacy in February 2009 with free, open access worldwide

• Future programming planned for HPS, including additional survey activity and action plan to implement Basel Statements

Next Steps

44

The ‘Moment’

www.fip.org/globalhosp