William A. Miller, Pharm.D., MSc, FASHP, FCCPProfessor Emeritus, University of Iowa

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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

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

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.

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)

1. Pharmacy leaders set the direction for the department

2. Leaders do things right and managers do the right thing

3. Mangers have a short term view and leaders have a long term view

4. Pharmacy leaders have a clear vision5. Pharmacy leaders build relationships with

other hospital leaders

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

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

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

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

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

• 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

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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

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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?

– 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

Rogers EM. Diffusion of Innovations

A

B

Rogers EM. Diffusion of Innovations

Move up the curve

Shift the curve to the left

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

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)

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

• 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

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

1. Evidence of the value of teams is sufficient2. Evidence of the value of clinical pharmacy

services is insufficient3. The diffusion of clinical pharmacy services,

as an innovation, was quite rapid4. Inadequate funding of clinical pharmacy

services as a part of health care reform is a potential threat to pharmacy

5. The “Medical Home Model” may provide an opportunity to expand clinical services in ambulatory care settings

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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

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Integrated model◦ One pharmacist job description◦ All pharmacists provide distributive and clinical

services concurrently◦ Pharmacists rotate to central and decentralized

practice areas

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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

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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

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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

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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

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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?

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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

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Director

Pharmacists

Central staffingrotation

Decentralized staffingrotation

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Director

Central Pharmacists

Select CentralPharmacists:

Targeted Monitoringand MTM

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Director

Assistant DirectorCentral Pharmacy

CoordinatorClinical Services

Assistant DirectorOutpatient Services

OutpatientDispensingPharmacists

CentralPharmacists

DecentralizedPharmacists

ClinicalSpecialists

ClinicalSpecialists

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Director

Assistant DirectorInpatient Services

Assistant DirectorOutpatient Services

CentralizedServices/Lead

DecentralizedServices/Lead

Clinical Pharmacists

Clinical Specialists

Central Pharmacists

Centralized Services/Lead

OutpatientPharmacists

Clinical Specialists

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CHIEF PHARMACY

OFFICER

DirectorTransplantation

Services

DirectorMedical and

SurgeryServices

DirectorOncology Services

Team Leaders forClinical Pharmacists

and Specialists

DirectorPediatric Services

Team Leaders forClinical Pharmacists

and Specialists

DirectorPsychiatry Services

DirectorOutpatient Services

DirectorCentral Inpatient

Pharmacy Services

Team Leaders forClinical Pharmacists

and SpecialistsFurther organization Central Pharmacists

Team Leaders forClinical Pharmacists

and Specialists

Team Leaders forClinical Pharmacists

and Specialists

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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

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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

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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.

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?

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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

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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)

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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

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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

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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 affected

by advances in health care, new drugs, pharmacogenomics, advanced decision support systems

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Model Effect on Cognitive Services Provided Cognitive Domain Affective

Domain

Evaluation

Synthesis

Analysis

Application

Comprehension

Knowledge

Characterization

Organization

Valuing

Responding

Receiving

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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

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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.

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Number of patients per clinical pharmacist or specialist ◦ Currently see150 to 30 for regular patient care

units, ICUs: 60 to 10◦ The higher the patient number the less involved

pharmacists are in the care of individual patients◦ Lack of pharmacy metrics◦ Miller Numbers for Optimal Clinical Services: ICUs

20 maximum, patient care units, 40 maximum◦ Numbers affect the ability to use an integrated

service practice model for all clinical pharmacists

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Use of pharmacy technicians for order fulfillment◦ Medication histories and reconciliation◦ Tech-tech programs◦ Routine clinical monitoring

Use of automation and use of information technologies available to increase efficiency and safety of medication use systems◦ CPOE◦ Access to information: PC, Tablets, Remote◦ Pharmacy computer system: SOAP, monitoring data,

evidenced-based recommendations◦ Use of ADC as unit dose carts◦ Use of order scanning technologies◦ Use of bar-coding and electronic-MARs◦ Decision support

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Physician and nursing practice models◦ Interdisciplinary teams in teaching hospitals versus

private practice model◦ Hospitalist model

Opinions of key leaders in the organization◦ Pharmacy, medical, nursing and administrative leaders◦ Are clinical pharmacists essential to patient care teams,

desirable, or primarily valued as a drug information resource or for teaching medical residents?

Opinions of professional organizations◦ Physician organizations: Critical care, ID, transplant,

oncology, pediatrics◦ Pharmacy organizations: ASHP Best Practices, PPMI, and

ACCP statements Organizational effectiveness research

◦ Research on best practice models

Are the involved pharmacists capable of performing the new role?

Will the proposed change be perceived as adding value to the jobs of the involved pharmacists?

Will the perception by the involved pharmacists of the probability of value satisfaction from the role change be sufficient to gain their support?

The pharmacists involved must not perceive the cost of the change in role as being significant.

Involved pharmacists perception of the risk of making the change should be low.

1. No one model is the best fit for all pharmacy organizations

2. The number and quality of staff affects the pharmacy practice model selected by pharmacy directors

3. Increased use of information technology and automation enhances patient safety and the delivery of clinical pharmacy services

4. All pharmacists should have the same qualifications and job descriptions

5. Chief Pharmacy Officers are more frequently appointed in large hospitals or health care systems

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Critically analyze the effectiveness and efficiency of your current practice model

Design and implement a model that◦ Optimizes the influence of pharmacy on patient

care outcomes: effectiveness, safety and efficiency

◦ Is a good fit for your institution◦ Is efficient, synergistic and coordinated

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◦ Results in pharmacists being essential members of interdisciplinary teams

◦ Places the interests of pharmacy leaders or individual pharmacists secondary to what is the best model for your patients

Develop metrics to evaluate the effectiveness and efficiency of your practice model and revise the model as needed

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