Regional Pharmacy Model

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Project 6.2 Regional Pharmacy Model

© Winnipeg Regional Health Authority, 2004

Table of Contents Sections Executive Summary......................................................................................................i 1. Introduction.........................................................................................................1 2. Organizational Structure, Role, Authority, and Accountability ...................2 3. Recruitment and Retention ..............................................................................22 4. Drug Distribution................................................................................................33 5. Clinical Pharmacist Support ............................................................................44 6. Adequate Pharmacy Staffing Levels ..............................................................54 7. Communication Plan.........................................................................................59 8. ABC 6.2 Pharmacy Regional Model Team Members..................................60 Appendices Appendix 1 Resource List ............................................................................................61 Appendix 2 Proposed Regional Pharmacy Program Organizational Chart .........63 Appendix 3 Regional Pharmacy Managers’ Survey................................................64 Appendix 4 Regional Pharmacy Model Survey Results..........................................68 Appendix 5 Regional Pharmacy Program Career Ladder ......................................70 Appendix 6 ABC Staffing Adjustment Financial Plan..............................................73


© Winnipeg Regional Health Authority, 2004 i

Executive Summary

With the regionalization of Winnipeg’s hospital-based health care services in 1998, the opportunity existed to not only address facility-specific pharmacy needs, but also to realize the potential for a more effective and efficient Regional Pharmacy Program. It was envisioned that pharmacy services could be reorganized in such a way that it would be possible to exploit the opportunities that exist for sharing of resources, reduce duplication of effort, and standardize pharmacy services within the Winnipeg hospital system. In an effort to realize this potential, pharmacy services were organized as a regional program in 1998 and a new organizational model for pharmacy was created. Looking back six years later, in 2004, the management model developed in 1998 has proven to have both its strengths and its weaknesses. Many accomplishments can be attributed to the model, including significant regional improvements and standardization of services in the portfolios managed by each of the Regional Pharmacy Managers. However, a number of model-related issues have been identified over the last six years. An external review of the Regional Pharmacy Program in 2001 (Wilgosh/Hunter Review1) identified a number of these issues and provided recommendations for addressing these problems. Some of the recommendations were accepted and implemented while others, notably those that dealt with the reporting relationships within the Regional Pharmacy Program, were not implemented at that time.

In 2002, as part of a larger benchmarking review of the WRHA, an external review of the Regional Pharmacy Program was conducted by Deloitte and Touché. With respect to the Regional Pharmacy Program the External Review identified:

• A need to provide clear direction for the role and authority of the

Regional Pharmacy Program team in comparison to the roles and authority of the site pharmacy program teams.

• A need to reduce the barriers between the Regional Pharmacy Program and the site-based pharmacy programs through improved communications and reduced competition.

• That pharmacy staffing levels at most facilities within the WRHA are below peer levels.


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• A need to make manpower investments at acute care sites. Short-term/immediate reinvestment is recommended at SBGH.

• A shortage of pharmacists throughout the health care system. • An increasing demand for clinical pharmacist support. • A need to formalize a regional approach to recruitment and retention of

pharmacists. • That more efficient drug distribution processes within the pharmacy

program could free up pharmacist resources and allow them to be redirected from drug distribution to clinical roles.

• That at some sites, nursing staff expend considerable time ordering, stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems.

• The need for ongoing leadership and professional development of regional program teams.

The ABC Regional Pharmacy Model Project

Operating within the framework of the Achieving Benchmarks through Collaboration (ABC) Project, the Regional Pharmacy Model Project was requested to:

• Develop a regional philosophy and organizational model for the

pharmacy service. • Develop a model for providing all sites with a safe, effective and

efficient drug distribution system, accompanied by an appropriate level of clinical pharmacist support.

• Develop a regional approach to recruitment and retention of pharmacists to address vacancy issues in the profession system-wide.

• Develop a plan for reinvestment in pharmacy support at all acute care facilities to insure that pharmacy staffing levels are at national benchmark levels that are deemed sufficient to support the provision of quality pharmacy services.

Project Methodology

In order to accomplish the above objectives, the ABC Pharmacy Project Team undertook the following activities: • Review of relevant resource material • Received presentations from other WRHA regional programs • Surveyed site/regional pharmacy managers • Received presentations from Regional and Site Pharmacy Managers


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• Surveyed six other major Canadian health regions • Reviewed the ongoing work of the Pharmacy Regional Program.

Alignment with National Patient Safety Initiatives

It is worth noting that the implementation of these recommendations would serve to align the Regional Pharmacy Program’s focus with patient safety initiatives that have recently been recommended by the Canadian Society of Hospital Pharmacists (CSHP). In their December 2003 position paper, entitled “Impact of Hospital Pharmacists on Patient Safety”2, the CSHP reviewed the published literature on the impact that pharmacy services have on patient safety and concluded with the following statement and recommendations.

“Persistent efforts and continued system improvements are required to ensure patients are as safe as possible within our facilities.” 2

To that end, CSHP recommends that all stakeholders and decision-makers work together to accomplish the following: 1. Address (pharmacy) staff shortages within our health care facilities 2. Increase involvement of pharmacists in direct patient care activities 3. Improve drug distribution systems 4. Expand use of technology and automation 5. Increase use of computerized prescriber order entry (CPOE) systems 6. Improve medication-related adverse event reporting and analysis 7. Foster a collaborative approach to adverse event prevention All of these recommendations on patient safety are addressed either directly or indirectly in the ABC Pharmacy Project Team recommendations.

Alignment with Other ABC Nursing Related Initiatives

The Deloitte and Touché External Review identified that, at some sites, nursing staff spend considerable time ordering, stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems. In addition, ABC Project 2.3 – Care Delivery and Staffing, surveyed sites in the WRHA to assist with the redesign of nursing roles within the region. The enablers identified included pharmacy unit dose, Pyxis, and CIVA (centralized IV admixtures).


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The Pharmacy Project Team concurs with the findings of the External Review and the Care Delivery and Staffing Project Team, and believes that expanded unit dose/IV admixture services would significantly reduce the time that nursing staff currently spend performing medication-related activities. The Pharmacy Project Team also believes that the literature supports the positive impact that decentralized pharmacists’ activities have on nursing workloads. A number of the recommendations of the Pharmacy Project Team support ongoing WRHA Pharmacy initiatives aimed at expanded provision of unit-dose, automation of the drug distribution systems, and delivery of decentralized clinical pharmacist services. The Pharmacy Project Team believes that improved nursing staff efficiencies to those reported by peer hospitals, most of which have unit dose/IV admixture systems and higher levels of clinical pharmacy staffing, will be difficult to achieve without the implementation of the changes contained in this report.

Action Requested of the ABC Steering Committee

1. “Green” Recommendations - Approval of those recommendations

which have no ABC financial implications, and which can be implemented within the constraints of the existing WRHA/facility operating agreements; specifically recommendations numbers 7, 8, 9, 11, 12, 13, 15, 16, 18, 19, 20, 22, 23, 28, 29, 31, 32, 33, 34, 39, 40, 41, 42, 43, 44, and 45.

2. “Yellow” Recommendations - Referral, to Senior Management of the

WRHA, of those recommendations that require major policy decisions and/or are difficult or impossible to implement within the context of the existing WRHA/facility operating agreements; specifically recommendations numbers 1, 2, 3, 4, 5, 6, 25, 26, and 27.

3. “Red” Recommendations - Tabling, for future action, those

recommendations that have financial implications and cannot be implemented until reinvestment opportunities arise as a result of savings achieved through other ABC initiatives; specifically recommendations numbers 10, 14, 17, 21, 24, 30, 35, 36, 37, and 38.


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Recommendations

Organizational Structure, Role, Authority, and Accountability

#1 Yellow That Site Pharmacy Managers be directly accountable to the Regional Director of Pharmacy and be employed by the WRHA. Site Pharmacy Managers would have day-to-day responsibility for ensuring that their particular site’s pharmacy related needs were being met, and would have matrix reporting accountability to Site Senior Management with respect to established service expectations. #2 Yellow That the Regional Director of Pharmacy be responsible for the performance evaluation of site managers, with input requested from each site CEO/COO at the time of the performance appraisal. #3 Yellow That all pharmacy staff in the region become employees of the WRHA.

Note: The Project Team recognizes that support from Human Resources will be required to assist with implementation and ongoing support of this recommendation. The WRHA Human Resources Division is in the best position to advise if incremental WRHA HR resources would be necessary to support this change.

#4 Yellow That site pharmacy budgets for pharmacy staff and supplies be consolidated into a single regional budget, managed by the Regional Pharmacy Program.

Note: The Project Team recognizes that support from Finance personnel will be required to assist with implementation and ongoing support of this recommendation. The WRHA Finance Division is in the best position to advise if incremental WRHA Finance resources would be necessary to support this change.


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#5 Yellow

That the Regional Director of Pharmacy, in addition to his/her direct reporting relationship to the WRHA, have a matrix accountability to the site CEOs/COOs for the overall pharmacy services provided at each site.

#6 Yellow That the Regional Director of Pharmacy establishes a working relationship with site CEOs through regular meetings held at least quarterly or more frequently as required. The purpose of the meetings would be to discuss site and regional pharmacy issues, to inform regarding regional initiatives, and to solicit input as to the effectiveness of the pharmacy program.

#7 Green That a site/regional team decision-making model be adopted by the Regional Pharmacy Program that enables the team to make decisions that are binding on, and supported by, all members of the group. Principles would be developed to define the level of support (i.e. simple majority, consensus, unanimity) that was required for specific types of decisions. The need for unanimity would be reserved for exceptional circumstances. All team members would be held accountable for supporting and implementing group decisions.

#8 Green

That participation in WRHA approved initiatives undertaken by the Regional Pharmacy Program be mandatory at all sites, not optional.

#9 Green

That shared Site Pharmacy Manager positions be eliminated, and replaced by a full-time or part-time Site Pharmacy Manager position, based on the level of management responsibility at each site (e.g. staffing numbers, regional responsibilities, etc.)

Note: The implementation of this recommendation would require funding for 2 to 2.5 additional management positions. The Project Team believes that this funding should eventually be part of the 45.2 FTE positions that have been identified as being required to bring the regional pharmacy staffing to the national mean benchmark level. However, given that there is unlikely to be new funding available to the Regional Pharmacy Program


© Winnipeg Regional Health Authority, 2004 vii

in the immediate future from the ABC Project, other options for funding this change have been explored. Following discussion of this issue with the CEO and other senior managers at the VGH and GGH sites, agreement was reached that the pharmacy management issue needed to be addressed in the immediate short term. At those two sites (the VGH and GGH) there has been a persistent pharmacy vacancy problem, attributed in part to a deficit in pharmacy leadership at those sites. As a result, the Regional Pharmacy Program, the GGH, and the VGH are proposing that the funding required to have a dedicated pharmacy manager at each site be extracted from the vacant pharmacist positions at each site. Although this will reduce the total number of staff pharmacist positions at the VGH and GGH, it is not anticipated that this will have a major negative impact on the existing staff pharmacist workloads for several reasons. To begin with, the positions from which the funding will come have been persistently vacant for over two years. In addition it is anticipated that 25% to 50% of the Site Pharmacy Manager’s time at these sites will be committed to relieving front-line pharmacists of management activities that they have been assigned to perform in the absence of a full-time Site Pharmacy Manager at their site. By establishing a strong site pharmacy management presence it is hoped that the changes needed to create a highly desirable work environment for pharmacists at these two sites can be established.

There are no short-term financial implications of this change. The funding extracted from staff pharmacist positions will be sufficient to fund the increase of 0.5 FTE Site Pharmacy Manager at the GGH and the VGH. The VGH and GGH have agreed to this arrangement with the understanding that a high priority will be given to replacing the reallocated staff pharmacist funding, when ABC funding for the regional shortfall of 45.2 FTE pharmacy positions begins to flow. It is hoped that a similar change to full-time Site Pharmacy Managers could be made at the SOGH and CH sites, but the necessary vacant pharmacist positions are not available at this time to make that change.

#10 Red

That the two 0.5 FTE Regional Pharmacy Manager positions should be increased to one 1.0 FTE position and one 0.75 FTE position.

Note: The implementation of this recommendation would eventually require new funding for 0.75 FTE additional management position. Given


© Winnipeg Regional Health Authority, 2004 viii

that there is unlikely to be new funding available to the Regional Pharmacy Program in the immediate future from the ABC Project, the Pharmacy Project Team believes that this recommendation should be tabled until funding does become available. When funding becomes available to address the 45.2 FTE position shortfall in regional pharmacy staffing, this recommendation would then be revisited.

#11 Green That the ratio of management to front-line staff be maintained at or below the national benchmark.

Note: The overall number of site and regional pharmacy managers under the proposed new model (recommendations 9 and 10) would be approximately 18.0 FTEs. This would represent 5.1% of total pharmacy FTEs following the addition of the 45.2 FTEs required to bring the Regional Pharmacy Program staffing to mean benchmark staffing. That figure compares favorably to the national average of 5.4% for pharmacy management staff reported in the 2001/2002 Lilly hospital pharmacy survey.3

#12 Green That pharmaceutical care coordinators not be a part of the management structure. The clinical leadership role envisioned for these positions is felt to be more appropriately included within the role of “clinical leaders”. The role of “clinical leaders” has been defined as part of the career ladder for pharmacists that has been developed by the Regional Pharmacy Program.

Recruitment and Retention

Applicable to All Pharmacy Regional Program Staff #13 Green That the following initiatives be implemented or maintained as a means of supporting the recruitment and retention of all pharmacy staff: • Encourage the recruitment and retention of staff of aboriginal background. • Maintain competitive wages. • Provide flexible work hours. • Implement initiatives to create a quality work life for all staff.


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• Expand the role of the pharmacy technician. • Develop a fair and equitable education plan for all regional pharmacy

employees. • Provide opportunities for, and reward participation in, advanced education

programs. • Provide adequate time to participate in projects, research, etc. • Develop strategies to encourage women to increase their participation in

the workforce and in the area of management (flexible hours, daycare, etc.)

• Ensure manageable workloads by increasing staff to the levels identified in the External Review.

• Provide career laddering opportunities for all staff. • Acknowledge staff contributions, by providing appropriate reward and

recognition opportunities. • Address issues around inadequacy of workplaces, including problems with

facilities and equipment. • Improve the use of technology as a method of improving the quality of

work life. Examples include Pyxis implementation, ability to access patient information, etc.

• Provide mechanisms to involve staff in decision-making. • Develop a work culture that is friendly, team focused, and supportive. • Provide adequate management support, as good leadership is essential

for creating a work life conducive to recruitment and retention. • Provide adequate resources to support student placements. • Provide positive student experiences during their placement.

#14 Red Provide a $250 educational allotment per employee per year as part of the Regional Pharmacy Program’s budget. Education funds need to be managed as part of the Regional Pharmacy Program to ensure that the allocation of resources is in the best interests of the region.

Applicable to Pharmacists

#15 Green

Continue to participate in job fairs, particularly those in Saskatchewan and Manitoba.


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#16 Green Consider the employment of foreign-trained pharmacists, on a case-by-case basis, if the candidate has a current license to practice in Manitoba or is immediately eligible for license to practice.

#17 Red

Continue with tuition relief/return of service agreements. Based on current projections, 10-15 contracts would need to be available annually. #18 Green Continue to fund moving expenses for new pharmacist recruits. #19 Green Advocate for increased enrollment at the University of Manitoba. #20 Green Continue the WRHA hospital pharmacy residency program. #21 Red Increase pharmacy residency stipends to $40,000 per resident, in order to be competitive with other Canadian residency programs. #22 Green Develop a system to enable the sharing of clinical practice experiences and expertise across the region. #23 Green Provide a mentorship support system for pharmacists in the early stages of developing their clinical practice role. #24 Red Increase clinical time. The goal of the Regional Pharmacy Program is to achieve 60% clinical practice for all pharmacists.


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#25 Yellow Implement a comprehensive regional vacancy management strategy to insure that there is an equitable distribution of pharmacist manpower within the region. #26 Yellow Enable the region to use pharmacists staffing budgets as a regional resource, so that staff can be deployed as required to manage pharmacist vacancies, support training of new staff from other sites, etc.

Applicable to Pharmacy Technicians #27 Yellow Improve ability to provide relief coverage for technicians. The development of a casual pool may be beneficial. Drug Distribution #28 Green That funding for Pyxis and Cerner implementation at VGH remain as a high priority in the Regional Pharmacy Business Plan and proceed once funding is available. #29 Green That funding for Pyxis and Cerner implementation at GGH be included in the next Regional Pharmacy Program business plan, given that the GGH has recently made the decision to pursue Pyxis and Cerner implementation at that site. #30 Red That resources be made available to support expansion of IV admixture services at all sites. It is further recommended that the WRHA continue to explore opportunities to develop a centralized system for IV admixture.


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#31 Green

Continue with the steps required to expand Tech Check Tech and pursue other opportunities for expanding the role of technicians. This would include advocacy, on the part of senior management, for enabling changes to the provincial pharmaceutical act. #32 Green That the need for an increased number of technicians, as well as increased educational resources to ensure adequate training and quality assurance programs, be given a high priority when ABC funding becomes available for reinvestment in pharmacy services. #33 Green That implementation of the regional pharmacy information system proceeds as funding becomes available. Priority should be given to the sites that currently have the oldest and least effective pharmacy information systems, i.e. VGH and GGH. Automation of the drug distribution systems (Pyxis) at those two sites is dependent on these upgrades. #34 Green That an automated dispensing/packaging system for the long-term care beds at the DLC and MHC be implemented, once funding becomes available. #35 Red That the WRHA support the implementation of centralized unit-dose packaging for acute care sites, by approving the request for equipment funding. A system that is able to support the entire region is the ideal. Procurement of a regional automated packaging machine is essential as the existing ATC-212 drug packaging systems will no longer be supported by the manufacturer after 2006. The machines will have to be replaced at GGH, SOGH, and VGH.


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Clinical Pharmacist Support #36 Red That the WRHA Regional Pharmacy Program strives to achieve Clinical Pharmacy Support Level 2 and Level 3, as described in this report and supports the further development and implementation of clinical practice standards. It is recommended that the WRHA support this initiative by providing increased levels of staffing and improved drug distribution systems outlined in Sections 4 and 6 of this report. #37 Red That sufficient pharmacist staffing, as identified in the External Review, be provided to support the clinical, decentralized role of the pharmacist. #38 Red That sufficient pharmacy technician staffing, as identified in the External Review, be provided to support the clinical, decentralized role of the pharmacist. #39 Green That implementation of the drug distribution systems described in Section 4 of this report, and implementation of a comprehensive regional pharmacy information system at all sites, be given a high priority in capital planning for the region. #40 Green That the Regional Pharmacy Program continue its efforts to improve access to relevant patient information and drug information at the point of care. #41 Green That the Regional Pharmacy Program be encouraged to continue with the development and implementation of the career ladder for pharmacists. Its use as a means of reward and recognition be further explored with Human Resources and the applicable collective bargaining units. The Regional Pharmacy Program will continue to pursue the development and refinement of the Pharmacy Clinical Leader position.


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#42 Green That education and development programs for staff pharmacists be recognized as a necessary support for the successful implementation of the proposed career ladder. The creation of an educational support service within the WRHA’s Regional Pharmacy Program, as proposed in the Program’s Business Plan, is recommended. #43 Green That the Regional Pharmacy Program continues to pursue opportunities for extending clinical pharmacist support throughout the continuum of care.

Adequate Pharmacy Staffing Levels #44 Green That agreement in principle is affirmed to increase pharmacy staffing to benchmark levels over the next five years, commensurate with availability of resources. #45 Green That the Steering Committee endorses the ABC Regional Pharmacy Model team’s proposed plan to defer staffing allocation until funding becomes available. The Regional Pharmacy Program will then complete an in-depth assessment, analysis, and consultation when information regarding the availability and amount of funding for reinvestment is known. Once funding is secured, the Regional Pharmacy Management group will assess needs across the region, provide up to date recommendations, and proceed to implementation.


© Winnipeg Regional Health Authority, 2004 1

1. Introduction

The Regional Pharmacy Model project was tasked with examining and refining the regional approach for pharmacy services and developing a plan for investments in pharmacy staff and services across the region. A major goal for the WRHA Regional Pharmacy Model is to provide an organizational structure that supports pharmacy initiatives. The focus is on medication safety and maximizing the clinical role of pharmacists so that patients derive full benefit of the pharmacists’ involvement in their care. In order to achieve these goals, pharmacy service infrastructure must be consistently in place at all facilities, including a robust pharmacy information system and a modern, safe, efficient and reliable drug distribution system that frees pharmacist time for clinical activities. Appropriate staffing levels are crucial to the success of the overall plan. Recruitment and retention strategies need ongoing support to achieve and maintain staffing to national benchmark levels. The achievement of these goals would result in desired clinical outcomes and improved quality of life for the patients that are served, as well as effective utilization of material (medications, technology, etc.) and human (nursing and pharmacy) resources. This report describes the work of the team and provides recommendations for achieving these goals. The report has been divided into sections to reflect the sub tasks that the project team addressed. It is essential that each section not be considered in isolation as the sections describe pieces of a comprehensive pharmacy program and all aspects must be considered as supportive of the overall service delivery model.



2. Organizational Structure, Role, Authority, and Accountability

This section of the report will focus on the phase of the ABC project related to Organizational Structure, Role, Authority, and Accountability for the Pharmacy Regional Program and the resources required to support a regionalized approach to Organizational Structure, Role, Authority, and Accountability.

The External Review conducted by Deloitte and Touché identified that:

• There is a need to provide clear direction for the role and authority of the Regional Pharmacy Program team, as well as the roles and authority of the site pharmacy program teams.

• There is a need to reduce the barriers between the Regional Pharmacy Program and the site-based pharmacy programs through improved communications and reduced competition.

• There is the need for ongoing leadership and professional development of Regional Pharmacy Program teams.

To help address these issues, one of the objectives given to the ABC Regional Pharmacy Project Team was to develop a regional pharmacy model to provide further support to a regionalized approach to the management and delivery of pharmacy services. This report addresses changes to the organizational structure, role, authority, and accountability of the Regional Pharmacy Program that the Project Team believes are necessary to achieve this objective.

A. Organizational Structure, Role, Authority, and Accountability Overview

With the regionalization of hospital-based health care services in 1998, the opportunity existed to not only address facility-specific needs, but also to realize the potential for a more effective and efficient Regional Pharmacy Program. It was envisioned that pharmacy services could be reorganized in such a way that it would be possible to exploit the opportunities that exist for sharing of resources, reducing duplication of effort, and standardizing pharmacy services within the Winnipeg hospital system.



A.1. 1998 Regional Pharmacy Model

In 1998, when the WRHA’s pharmacy services were first organized as a regional program, a new organizational model for pharmacy was created.

Regional Pharmacy Managers

Regional Pharmacy management positions were included in the model. It was expected that many of the responsibilities previously dealt with on a site-by-site basis could be handled more effectively by pharmacy managers who would be responsible for addressing these needs from a regional perspective. In addition to the positions of Regional Director and Administrative Director for the Regional Pharmacy Program the following Regional Pharmacy Manager positions were created:

• Drug Procurement and Inventory Control (1.0 FTE) • Drug Distribution Systems and Investigational Drug Services

(1.0 FTE) • Drug Information/Drug Use Management (1.0 FTE) • Pharmacy Information Systems (1.0 FTE) • Educational Services (0.5 FTE) • Professional Practice Development (0.5 FTE)

Site-Specific Pharmacy Management Responsibilities

With the regionalization of the responsibilities described above, it was envisioned that there would be a change in the scope of responsibilities required of Site Pharmacy Managers. In the model implemented in 1998, it was anticipated that the emphasis of these individuals’ responsibilities would be more on day-to-day operations than they would be on planning and development activities. Specific responsibilities would include:

• Day-to-day supervision of pharmacy operations • Day-to-day human resource management • Resolution of site-specific issues/problems that arise on a day-

to-day basis • Liaison with facility management • Liaison with site-specific clinical program managers



• Liaison with other pharmacy managers responsible for region-wide initiatives

• Overseeing the collection and reporting of site-specific financial and operational data

The complement of pharmacy directors/assistant directors/ coordinators at each of the WRHA facilities was reduced as outlined in the table below:

Facility

Site-Specific Pharmacy

Management Staff 1998

WRH Site-Specific Pharmacy

Management After Regionalization

Net Change

Seven Oaks 1.0 0.5 - 0.5

Concordia 0.5 0.5 0

Grace 1.0 0.5 - 0.5

Victoria 1.0 0.5 - 0.5

Deer Lodge 1.0 0.5 - 0.5

Misericordia 1.0 0.2 - 0.8

Riverview 1.0 0.5 - 0.5

St. Boniface 4.0 3.0 - 1.0

HSC 4.5 3.0 - 1.5*

Total 15.0 9.2 - 5.8*

* Did not include HSC Pharmacy Director's position that had

already been deleted.

Sites with 0.5 FTE site management positions were given the option of combining the management of two sites under a single shared Site Pharmacy Manager, or employing a Site Pharmacy Manager on a 0.5 FTE basis. Shared Site Pharmacy Manager positions were eventually agreed upon for the VGH/GGH sites, the CH/SOGH sites, and the DLC/MHC sites. Riverview opted to employ its own 0.5 FTE Site Pharmacy Manager.



Pharmaceutical Care Coordinators

Unlike most other allied health disciplines, it was recognized that a large portion of the pharmacy services delivered to the WRHA clinical programs would come from a centralized pharmacy department at each site that would simultaneously serve multiple clinical programs. It was therefore felt to be important that, in the absence of direct clinical program control of pharmacy resources, the Regional Pharmacy Program develop organizational links to the clinical programs as a means of insuring that the needs and concerns of the clinical programs would be addressed. In the planning discussions that had occurred, it had been suggested that these clinical service coordinators would be individuals who were actively involved in the provision of clinical services to a specific clinical program. Their job would be to serve as the liaison between the regional pharmacy service and the clinical programs. The management responsibilities of these clinical staff were anticipated to occupy only a small proportion of the coordinator’s time, in comparison to their clinical responsibilities. In general, it was thought that the issues brought forward by these coordinators would be addressed by other pharmacy managers with site or regional management responsibilities. No back filling of clinical time was therefore anticipated to be necessary for the limited management responsibilities they would assume. These coordinator positions were not filled initially, but in 2001, on a two-year trial basis, two Pharmaceutical Care Coordinators were appointed as liaisons to the Medicine and Child Health Clinical Programs.

A.2. Accountability Relationships within the

Regional Pharmacy Program

It was initially proposed that all pharmacy managers in the WRHA have a direct line of accountability to the Regional Director of Pharmacy. The Site Pharmacy Managers would also have a secondary accountability relationship to senior management at their site, and Pharmaceutical Care Coordinators would have a secondary accountability relationship to their clinical program. Following discussions with the site CEOs and Senior Management of the WRHA, a decision was made that Site Pharmacy Managers



would have a dual reporting relationship to both their site and the Regional Pharmacy Program. Most sites have interpreted the model as being one where Site Pharmacy Managers have a direct accountability relationship to their site, and a secondary accountability relationship to the Regional Pharmacy Program.

A.3. Issues Related to the Regional Pharmacy

Management Model

Looking back six years later, in 2004, the management model developed in 1998 has proven to have both its strengths and its weaknesses. Many accomplishments can be attributed to the model, including significant regional improvements and standardization of services in the portfolios managed by each of the Regional Pharmacy Managers. However, a number of model-related issues have been identified over the last six years. An external review of the Regional Pharmacy Program in 2001 (Wilgosh/Hunter Review1) identified a number of these issues and provided recommendations for addressing these problems. Some of the recommendations were accepted and implemented while others, notably those that dealt with the reporting relationships within the Regional Pharmacy Program, were not implemented at that time.

The major issues that the ABC Pharmacy Project Team has identified as ones that require action in order to address its mandate related to the organizational structure, role, authority, and accountability of the Regional Pharmacy Program can be summarized under the following headings:

Accountability Relationships and Their Impact on the Timeliness and Quality of Decision-Making

The current organizational structure and reporting relationships within the Regional Pharmacy Program work best when the Regional Pharmacy Program and all sites agree that a particular issue must be addressed collectively, and also agree on the course of action that must be taken to address the issue. The model has often not worked well in the face of disagreements in these areas, largely because of the absence of a shared accountability relationship. Some Site Pharmacy Managers have reserved the right to opt out of regional initiatives, either on the basis of their site’s direction or their own personal judgment concerning the



merits of a particular initiative. Most regional initiatives are not viable without the participation of all sites, so the need for unanimity has prevented or delayed a number of efforts to improve the way pharmacy services are managed. Even when these issues have ultimately been overcome, the lengthy time required to make decisions has resulted in missed opportunities, and allowed some problems to progress to crises. It can also be argued, as the Deloitte and Touché report suggested, that the need for unanimity has resulted in “strategy dilution”, since any changes must be perceived by all sites as being beneficial and relatively risk-free.

The lack of clarity in the accountability relationships has also been detrimental to personal relationships within the Regional Pharmacy Program. On a number of occasions, disagreements within the Regional Pharmacy Program have been elevated to higher levels for dispute resolution. In that scenario there has usually been a winner and a loser, which does not contribute to the maintenance of a collaborative working relationship amongst the pharmacy managers.

Budget Management Issues

The Regional Pharmacy Program as a whole has consistently achieved a budget surplus at year-end. There have, however, been instances where a particular site pharmacy required additional resources in order to address a short-term problem. Although there were surpluses in other sites that could have been used to address the problem, the Regional Pharmacy Program was not able to utilize those resources to do so. There have also been situations where the Regional Pharmacy Program could have benefited from overspending at a particular point in the year, knowing that under spending would occur later in the year (e.g. over-hiring of pharmacists from the graduating class in the spring of the year, knowing that unfilled vacancies, and the associated accumulation of a surplus, could be anticipated by late fall of each year). The site-based management of pharmacy budgets, as part of their overall site budget management, has not allowed this to occur. The Regional Pharmacy Program has not been able to manage its budgets as a collective resource, in order to allow these types of actions to be taken. This creates significant obstacles to the



implementation of regional on-call services, regionalization of drug information resources and services, centralization of repackaging functions, centralization of IV admixture services, etc.

Staff Management Issues

The Regional Pharmacy Program has not been able to manage its staff resources as a collective whole. This has negatively impacted on the ability of the Regional Pharmacy Program to manage a number of pharmacy manpower issues. It is also an obstacle to the sharing of educational resources, since the sites with “experts” do not see the benefit to their site of allowing time for those individuals to train and educate staff at other sites. This inability to manage staff as a regional resource will be particularly problematic when the Program is in a position to undertake changes such as the centralization of repackaging functions, the centralization of IV admixture services, and the regionalization of drug information services.

Shared Site Pharmacy Manager Workloads

The workload of the shared Site Pharmacy Managers has been a problematic issue. There are probably a number of reasons why this problem has persisted. It is possible that the original model did not adequately consider the extent of the pharmacy management responsibilities that would remain at each site. However, some other regions throughout the country have shared Site Pharmacy Manager positions that appear to be working, although the facilities they are managing are smaller than the sites being managed by the WRHA’s shared Site Pharmacy Mangers. It is also possible that the success of the Regional Pharmacy Manager positions has created significant new workload for the Site Pharmacy Managers who are usually actively involved in the implementation of new regional pharmacy initiatives, related to the many changes that have been taking place. (See Appendix 3 Regional Pharmacy Managers’ Survey) Site expectations of the Site Pharmacy Managers also contribute to the workload demands. Many sites have not altered their expectation that their Site Pharmacy Manager be an active participant in the general management activities at each of their sites. This has led to a situation where Site Pharmacy Managers



are expected to participate in all of the usual management meetings at each of their two sites, to receive and act upon all of the e-mail and site management requests at both of their sites, and to participate in social activities at each of their sites. Regardless of the relative contribution of each of these factors, it has become clear that the workload demands placed upon Site Pharmacy Managers must be addressed. This can either be achieved through a reduction in the workload demands, or by returning to a model where there is a full-time pharmacy manager at most of the WRHA sites.

Part-Time Regional Pharmacy Manager Positions

The part-time Regional Pharmacy Manager positions have also proven to be challenging for the incumbents. This has been particularly true of the Educational Services position. The demands of managing student placements, coordinating lecturing by regional pharmacy staff involved in teaching programs at the University, managing the training of new staff, and managing the pharmacy residency program have proven to be excessive. In the last two years the Regional Pharmacy Program has, in its section of the regional health plan, identified the need for a substantial increase in the human resources committed to the delivery of educational services within the WRHA. That plan has anticipated an increase in the position of Regional Pharmacy Manager-Educational Services from 0.5 FTE to 1.0 FTE.

In the case of the Regional Pharmacy Manager - Professional Practice Development, the workload has also been challenging. However, the incumbent emphasized to the ABC Project Team that the maintenance of a clinical practice, at least on a part-time basis, was very important for this position. The Team concurred with his assessment. After further discussion it was agreed that an increase in the Regional Pharmacy Manager - Professional Practice Development from 0.5 FTE to 0.75 FTE would be recommended by the ABC Pharmacy Team.



B. Benefits of Implementing Changes to the Organization, Role, Authority, and Accountability of the Regional Pharmacy Model The implementation of a more regionalized approach to the management and delivery of pharmacy services will result in a Regional Pharmacy Program that provides desired clinical outcomes, improved quality of life for patients, a high quality of work life for staff, and effective and efficient utilization of human and material resources. Benefits that would result from the implementation of the proposed model include: For Clients Patients and other caregivers are the ultimate beneficiary of pharmacy services. It is anticipated that a more effective and efficient organizational structure, resulting in improved accountability relationships, will facilitate the implementation of many of the regional pharmacy initiative that have been developed to help us achieve the Regional Pharmacy Program’s Vision 2007 statement:

By the year 2007, WRHA Regional Pharmacy Services will consist of:

• A comprehensive system of safe medication practices

• Pharmacy staffing and service levels that compare favourably to benchmarks for similar Canadian health care organizations

• A pharmacy practice model for the provision of patient-oriented services (clinical pharmacy/pharmaceutical care), that is applied consistently throughout the region, across the continuum of care

• Appropriately-resourced, targeted ambulatory care pharmacy services

• Contemporary, state-of-the-art drug distribution systems



• A regional pharmacy information system, and other information technology systems, that support staff in their day to day activities and facilitate communication within and beyond the pharmacy program

• A drug use management system that ensures optimal, cost-effective use of drug therapies

• Efficient and effective pharmaceutical contracting, procurement, and inventory control systems

• An effective and accessible staff development program

Which collectively will achieve:

• Desired clinical outcomes and improved quality of life for the patients that we serve

• A high quality of work life for staff of the Regional Pharmacy Program

• Effective and efficient utilization of human and material resources

For Staff As stated in our Vision 2007 statement, the achievement of the objectives laid out for the Regional Pharmacy Program would be expected to result in “a high quality of work life for staff of the Regional Pharmacy Program.” The clarification of reporting relationships, common employment rules, and more consistent and timely management of labour issues are expected to facilitate achievement of this goal. Staff will also benefit from having a full time site manager available to provide leadership and support. For Sites It is recognized that the sites may have some concerns about the loss of direct control over their pharmacy managers, staff and budgets. However, it is felt that the sites will be in a better position to insist on greater consistency regarding the provision of pharmacy services across all sites. Sites will also benefit from improved management of pharmacy manpower resources, and from the achievement of the objectives laid out in the Vision 2007 statement, which are more likely to be achieved under the new pharmacy



organizational structure. The sites with shared Site Pharmacy Managers will also benefit from the inc reased presence of the pharmacy manager at their site. For Clinical Programs The clinical programs would also benefit from the implementation of many of the regional pharmacy initiatives that have been developed to help us achieve our Vision 2007 statement. For the Regional Pharmacy Program The Regional Pharmacy Program would be much better positioned to achieve its Vision 2007 Statement and to move forward effectively into the future. The infusion of additional management resources would assist the Regional Pharmacy Program in developing and implementing a pharmacy management succession plan. For the WRHA The WRHA would benefit from the improved regional approach to provision of pharmacy services, more effective and efficient utilization of pharmacy resources, and more effective management of pharmacy manpower issues.

C. Consultations with Stakeholders and ABC Team Methodology The ABC project team reviewed and discussed the current regional structure as well as conducting the following activities: a. Review of Relevant Resource Material (See Appendix 1:

Resource List)

b. Presentations by Other WRHA Regional Programs 1. Laboratory Medicine Program – Keith McConnell 2. e-Health – Ian Fish



c. Site/Regional Pharmacy Managers’ Survey (See Appendix 3: Regional Pharmacy Managers’ Survey) Surveyed management group to determine issues and workload items.

Key Points

Overall the survey indicated that the matrix reporting relationship was confusing and often frustrating for the site managers and that managing two sites frequently resulted in unrealistic demands.

d. Survey of Major Canadian Health Regions (See Appendix

4: Regional Pharmacy Model Survey Results)

Survey was designed to identify key elements inherent in a successful Regional Pharmacy Program.

Key Points

All surveyed regions reported that Pharmacy is structured as a Regional Program. All sites reported that pharmacy managers and staff report to the Regional Director of Pharmacy. With the exception of the Capital Health Region in Edmonton, the regions surveyed reported that all pharmacy staff are employed by the region. In Edmonton, staff within the Caritas group of hospitals are employed by the Caritas sites, not by the region. However, the day-to-day reporting relationships are aligned to the Regional Pharmacy Program.

e. Presentations by Regional Managers and Site Managers

Regional and site managers provided information regarding the key job responsibilities and identified aspects that were working well and areas requiring improvement. Key Points

• Site Pharmacy Managers identified that a single line of

accountability would result in more effective and



responsive management of pharmacy services and human resources.

• There was a desire for increased clarity around responsibility and accountability in regards to implementation of initiatives.

• The need to align the financial resources as well as the reporting relationship was identified.

• At the sites where there are shared Site Pharmacy Managers, Senior Pharmacists have been drawn away from their front-line clinical roles to provide management support, particularly when the Site Pharmacy Manager is off-site.

• The organizational structure should support a practice environment, which supports an enhanced clinical role for staff pharmacists.

D. Recommendations Related to Organization, Role, Authority, and Accountability of the Regional Pharmacy Program The Project Team recommends: #1 Yellow That Site Pharmacy Managers be directly accountable to the Regional Director of Pharmacy and be employed by the WRHA. Site Pharmacy Managers would have day-to-day responsibility for ensuring that their particular site’s pharmacy related needs were being met, and would have matrix reporting accountability to Site Senior Management with respect to established service expectations. #2 Yellow That the Regional Director of Pharmacy be responsible for the performance evaluation of Site Pharmacy Managers, with input requested from each site CEO/COO at the time of the performance appraisal.



#3 Yellow

That all pharmacy staff in the region become employees of the WRHA.

Note: The Project Team recognizes that support from Human Resources will be required to assist with implementation and ongoing support of this recommendation. The WRHA Human Resources Division is in the best position to advise if incremental WRHA HR resources would be necessary to support this change.

#4 Yellow That site pharmacy budgets for pharmacy staff and supplies be consolidated into a single regional budget, managed by the Regional Pharmacy Program.

Note: The Project Team recognizes that support from Finance personnel will be required to assist with implementation and ongoing support of this recommendation. The WRHA Finance Division is in the best position to advise if incremental WRHA Finance resources would be necessary to support this change.

#5 Yellow That the Regional Director of Pharmacy, in addition to his/her direct reporting relationship to the WRHA, have a matrix accountability to the site CEOs/COOs for the overall pharmacy services provided at each site. #6 Yellow That the Regional Director of Pharmacy establishes a working relationship with site CEOs through regular meetings held at least quarterly or more frequently as required. The purpose of the meetings would be to discuss site and regional pharmacy issues, to inform regarding regional initiatives, and to solicit input as to the effectiveness of the pharmacy program.



#7 Green That a site/regional team decision-making model be adopted by the Regional Pharmacy Program enabling the team to make decisions binding on and supported by all members of the group. Principles would be developed to define the level of support (i.e. simple majority, consensus, unanimity) that was required for specific types of decisions. The need for unanimity would be reserved for exceptional circumstances. All team members would be held accountable for supporting and implementing group decisions. #8 Green That participation in WRHA approved initiatives undertaken by the Regional Pharmacy Program be mandatory at all sites, not optional. #9 Green That shared Site Pharmacy Manager positions be eliminated, and replaced by a full-time or part-time Site Pharmacy Manager position, based on the level of management responsibility at each site (e.g. staffing numbers, regional responsibilities, etc.)

Note: The implementation of this recommendation would require funding for 2 to 2.5 additional management positions. The Project Team believes that this funding should eventually be part of the 45.2 FTE positions that have been identified as being required to bring the regional pharmacy staffing to the national mean benchmark level. However, given that there is unlikely to be new funding available to the Regional Pharmacy Program in the immediate future from the ABC Project, other options for funding this change have been explored.

Following discussion of this issue with the CEO and other senior managers at the VGH and GGH sites, agreement was reached that the pharmacy management issue needed to be addressed in the immediate short term. At those two sites (the VGH and GGH) there has been a persistent pharmacy vacancy problem, attributed in part to a deficit in pharmacy leadership at those sites. As a result, the Regional Pharmacy Program, the GGH, and the VGH are proposing that the funding required to have a dedicated pharmacy manager at each site be extracted from the vacant pharmacist positions at each site. Although this will



reduce the total number of staff pharmacist positions at the VGH and GGH, it is not anticipated that this will have a major negative impact on the existing staff pharmacist workloads for several reasons. To begin with, the positions from which the funding will come have been persistently vacant for over two years. In addition it is anticipated that 25% to 50% of the Site Pharmacy Manager’s time at these sites will be committed to relieving front-line pharmacists of management activities that they have been assigned to perform in the absence of a full-time Site Pharmacy Manager at their site. By establishing a strong site pharmacy management presence it is hoped that the changes needed to create a highly desirable work environment for pharmacists at these two sites can be established. There are no short-term financial implications of this change. The funding extracted from staff pharmacist positions will be sufficient to fund the increase of 0.5 FTE Site Pharmacy Manager at the GGH and the VGH. The VGH and GGH have agreed to this arrangement with the understanding that a high priority will be given to replacing the reallocated staff pharmacist funding, when ABC funding for the regional shortfall of 45.2 FTE pharmacy positions begins to flow. It is hoped that a similar change to full-time Site Pharmacy Managers could be made at the SOGH and CH sites, but the necessary vacant pharmacist positions are not available at this time to make that change.

#10 Red That the two 0.5 FTE Regional Pharmacy Manager positions should be increased to one 1.0 FTE position and one 0.75 FTE position.

Note: The implementation of this recommendation would eventually require new funding for 0.75 FTE additional management position. Given that there is unlikely to be new funding available to the Regional Pharmacy Program in the immediate future from the ABC Project, the Pharmacy Project Team believes that this recommendation should be tabled until funding does become available. When funding becomes available to address the 45.2 FTE position shortfall in regional



pharmacy staffing, this recommendation would then be revisited.

#11 Green That the ratio of management to front-line staff be maintained at or below the national benchmark.

Note: The overall number of site and regional pharmacy managers under the proposed new model (recommendations 9 and 10) would be approximately 18.0 FTEs. This would represent 5.1% of total pharmacy FTEs following the addition of the 45.2 FTEs required to bring the Regional Pharmacy Program staffing to mean benchmark staffing. That figure compares favorably to the national average of 5.4% for pharmacy management staff reported in the 2001/2002 Lilly hospital pharmacy survey.3

#12 Green That pharmaceutical care coordinators not be a part of the management structure. The clinical leadership role envisioned for these positions is felt to be more appropriately included within the role of “clinical leaders”. The role of “clinical leaders” has been defined as part of the career ladder for pharmacists that has been developed by the Regional Pharmacy Program. (See Appendix 2: Proposed Regional Pharmacy Program Organizational Chart) Primary changes will be: • Site Pharmacy Managers will have a direct reporting

relationship to the Regional Director of Pharmacy. • Shared Site Pharmacy Manager Positions will be eliminated in

favor of full-time or part-time Site Pharmacy Managers. • The FTE associated with the Regional Manager positions for

Education and Professional Practice will be increased. • All pharmacy staff will be employed by the region. • All pharmacy staff and supply budgets will be centralized and

managed by the Regional Pharmacy Program.



• A number of human resource and budget management issues will have to be identified, discussed and resolved prior to implementation of many of these recommendations.

Once approval in principle has been obtained a detailed implementation plan will be developed.

E. Financial Implications The Project Team recognizes that funding for ABC Pharmacy initiatives will not be made available until savings have begun to flow. As a result, no new funding for the Regional Pharmacy Program is being requested at this time. If, and when, funding to address the identified shortfall in regional pharmacy staffing (45.2 FTEs) does become available, approximately $300,000 to $400,000 would be used to fund the addition of 2.75 to 3.25 management EFTs to the Regional Pharmacy Program. This funding would support the elimination of shared site managers and provide increased support for the educational and professional practice positions at the regional management level. (See recommendations 9, 10, and 11.)

F. Evaluation The management survey will be administered 18 months after implementation.

G. Implications of Maintaining the Status Quo a. The Regional Pharmacy Program will not be able to manage its

budgets as a collective resource, which will create significant obstacles to the implementation of many of the regional pharmacy initiatives that are being pursued.

Examples include:

• Implementation of regional on-call services • Implementation of centralized repackaging o f

pharmaceuticals



• Implementation of centralized IV admixture production • Implementation of a regional drug information service • Implementation of a regional drug use management system • Implementation of a regional pharmacy education service

and funding • Implementation of regional human resource management

strategies • Implementation of regionalized pharmacy service delivery

(e.g. off-site pharmaceutical supply, regional NICU pharmacy services, regional oncology pharmacy services, etc.)

• Implementation of a standardized clinical pharmacy practice model, and pharmacy practice expectations, within the region.

b. The Regional Pharmacy Program will not be able to manage its

staff resources as a collective whole, which will create significant obstacles to the implementation of many of the regional service initiatives listed above.

c. Most regional initiatives are not viable without the participation

of all sites. In the past, Site Pharmacy Managers have reserved the right to opt out of regional initiatives. The resulting need for unanimity has prevented or delayed the implementation of many of the regional service initiatives listed above.

d. The sharing of expertise and educational resources will not

occur, since:

• The sites with “experts” do not see the benefit to their site of allowing time for those individuals to train and educate staff at other sites, and

• Sites with educational funding sources do not see the benefit to their site of sharing those resources with other sites.

e. Shared Site Pharmacy Managers may not remain in those

positions, and replacements would be difficult to recruit, given the unmanageable workloads and demands associated with those positions.



f. The Regional Pharmacy Manager positions presently occupied by part-time managers will not achieve their objectives in a timely manner, given the limited management time available to pursue their management responsibilities.



3. Recruitment and Retention

This section of the report will focus on the phase of the project related to recruitment and retention for the Pharmacy Regional Program and the resources required to support a regionalized approach to recruitment and retention. In regards to recruitment and retention of pharmacy staff, the External Review conducted by Deloitte and Touché identified that: • Pharmacy staffing levels at most WRHA facilities were below peer

levels • There was a need to make manpower investments at acute care sites • A shortage of pharmacists existed throughout the health care system • There was an increasing demand for clinical pharmacist support To help address these issues, one of the objectives given to the ABC Regional Pharmacy Project Team was to develop a regional approach to recruitment and retention of pharmacists and pharmacy technicians to address vacancy and retention issues within the WRHA. This section of the report provides support for the current recruitment and retention efforts and makes additional recommendations that the Project Team identified as being necessary to achieve this objective. A. Workforce Shortages Overview

1. Historical Context

A shortage of staff pharmacists first became problematic for the WRHA facilities in 1999. Prior to that time the hospital sector had experienced little difficulty in recruiting and retaining pharmacists; in fact it had been considered to be the preferred area of practice by the majority of new graduates both because of the quality of professional work life and an overall compensation package that was superior to that being offered by most community pharmacies. By the spring of 2000, the HSC had a pharmacist vacancy rate approaching 25% which resulted in a number of initiatives to manage the shortage, including:



• Workload reduction through the closure of the HSC outpatient pharmacy, which had previously employed 9.25 FTE pharmacists and the cancellation of contracts with external agencies which reduced staffing needs by a further 2.0 FTEs.

• Recruitment and retention initiatives, including an advertising

campaign across Canada, an active program for the recruitment of foreign-trained pharmacy graduates, more generous relocation support, an adjustment in salaries as part of the 2000 to 2003 contract renewal, and a $3000 personal education fund for all staff pharmacists at the HSC site.

• Improvement in the quality of professional work life through

initiatives such as expanded roles for pharmacy technicians, expanded use of modern pharmacy technologies (computer systems, automated dispensing technologies, portable information devices such as Palm Pilots), and more clinical time for staff pharmacists.

Although the shortage was initially problematic only at the HSC, by 2001 similar shortages were apparent at most acute care sites and the $3,000 personal education fund had been extended to several other sites as a recruitment and retention incentive.

By May of 2002 the regional vacancy rate was in excess of 15%. In June of 2002 the resignation of most of the GGH pharmacists, which occurred as a result of the increasing wage differential between the public and private sector, led to an acute regional pharmacist staffing crisis that necessitated the implementation of the mobility agreement and the temporary reassignment of pharmacists from other WRHA sites to maintain pharmacy services at the GGH site.

In July of 2002 a one-year $20,000 recruitment and retention allowance was implemented for all staff pharmacists employed by the WRHA, and other regional health authorities in Manitoba, in order to bring hospital salaries more in line with those in the private sector. Manitoba Health funded this recruitment and retention allowance. In September of 2002 a $10,000 tuition relief incentive, tied to a one-year return of service agreement, was implemented to assist with the recruitment of 2003 pharmacy graduates. Eight students were recruited under this arrangement, five from the University of Manitoba and three from the University of Saskatchewan. Additional graduates



could have been recruited with this plan, if more than eight positions had been offered. The funding for this $80,000 expense was shared equally by the WRHA and the sites where the return-of-service pharmacists became employed.

2. Extent of Shortages

As noted above, the shortages affected sites differentially over time. The HSC site experienced prolonged vacancy rates, which were approximately 10% to 25% over the 2000 to 2002 time period. In the early summer of 2002, vacancy rates reached 38% at the VGH and 70% at the GGH, leading to the implementation of recruitment and retention incentives that have produced a steady decline in pharmacist vacancy rates. The February 2003 regional vacancy rate was approximately 6%, a 0% vacancy rate was achieved in May 2003 when the 2003 return-of-service graduates entered the WRHA workforce, and by February of 2004 the vacancy rate had returned to approximately 6%. Unfortunately the competition for new graduates from the class of 2004 was intense, and the WRHA was only able to recruit 6 of 10 graduates that it was prepared to hire under a return-of-service program identical to the one offered in 2003. As a result, it is expected that the vacancy rate in 2004/2005 will once again be problematic.

3. Shortages in Other Sectors

Pharmacist shortages have been a serious problem in both the public and private sectors of employment within Manitoba. Brandon Regional Health Authority had reached a 65% vacancy rate in early 2002, and had implemented a one-year $20,000 recruitment and retention allowance for pharmacists several months before the WRHA did so. The private sector, which provides pharmacy services to most long term care and community-based patients, has been experiencing significant recruitment and retention problems for a number of years. This led to a rapid escalation in the salaries being offered to pharmacists, which exacerbated the recruitment and retention problems within the public sector where salaries were governed by multi-year union contracts.



4. Key Impacts of Shortages

The pharmacist shortages have resulted in outpatient and inpatient service reductions, loss of revenue generated through retail pharmacy operations, an inability to respond to opportunities for improving and expanding pharmacy services, and a deterioration in working conditions within the WRHA pharmacy program. Within the WRHA there has been an increasing demand for clinical pharmacist support. A significant impact of the pharmacist shortage has been the inability to provide an appropriate level of clinical pharmacist support, which impacts negatively on patient safety and staff satisfaction.

Reasons for Pharmacist Shortages

Pharmacist shortages are an international problem that is affecting virtually all developed countries. The major cause is one of increased demand for pharmacists, arising both from increased use of pharmaceuticals by society and an expansion of the role of the pharmacist. The role expansion for pharmacists has largely occurred in response to the perceived need for better management of pharmaceutical use, both to reduce costs and to produce better drug therapy outcomes. The supply of pharmacists has not increased quickly enough to keep pace with the increased demand.

Within Manitoba the shortage has been exacerbated by a number of factors, including:

• The university system in Manitoba graduates a relatively small

number of pharmacists per unit of population, in comparison to most other Canadian Faculties of Pharmacy. For example Manitoba and Saskatchewan, with similar populations, graduate approximately 45 and 70 pharmacists respectively each year.

• The Internet/International Mail Order Pharmacy business, that

provides service primarily to American consumers, was largely born in Manitoba and has seen its most spectacular growth in this province. The demand for pharmacists by this sector has been rapidly increasing. Internet pharmacies have been willing to pay very high wages, and provide very attractive recruitment and retention incentives, in order to acquire the pharmacists that they need to respond to the business growth that they have been experiencing.



• Most pharmacists who were eligible to retire from the WRHA facilities have exercised that option, while continuing to work part-time or full-time in the private sector. They are able to draw their pensions while:

§ Gaining the freedom to work as many or as few hours as they

like § Eliminating the need to work evening, night, or weekend shifts § Receiving higher wages § Working in a less stressful environment

Working conditions in some WRHA hospitals have contributed to the difficulty in recruitment and retention of pharmacists. The Deloitte and Touché external review of the WRHA facilities validated the Regional Pharmacy Program’s longstanding position that the WRHA pharmacies are significantly understaffed in relation to their peer group of hospitals across Canada. Demanding shift work schedules, inadequate educational opportunities, limited career advancement opportunities, extremely high workloads, a growing vacancy rate, and low wages have contributed to the now widely held belief among pharmacists that hospitals are no longer a preferred employer.

B. Recruitment and Retention - Standards and Goals

The goal of the Regional Pharmacy Recruitment and Retention plan is to achieve vacancy rates that are 3%, or below on an annual basis and a recruitment rate of 20 pharmacists annually.

C. Regional Recruitment and Retention Initiatives

A number of recruitment and retention initiatives have been mentioned above, including:

• The implementation of personal educational funds at several sites • Print advertising in newspapers across Canada and in national

pharmacy journals • Participation in job fairs organized by Faculties of Pharmacy across

Canada



• The recruitment of foreign-trained pharmacists (8 were recruited, although only 3 of those remain employed by the WRHA as of April 2004)

• Quality of work life initiatives (expanded technician roles, better use of technology, more clinical time, etc.)

• The implementation of a $20,000 per year recruitment and retention allowance for all pharmacists in the WRHA

• The implementation of a $10,000 tuition relief/return-of-service incentive for 2003 and 2004 pharmacy graduates

Workforce Vacancy Forecasting

If competitive salaries are maintained, it is anticipated that annual turnover rates will return to their historical levels of approximately 10%. Within the WRHA, that translates to an annual demand for approximately 15 new pharmacists each year to maintain existing staffing levels. In addition, it is hoped that the ABC Initiative will achieve its goal of bringing all disciplines to their peer group’s mean benchmark staffing level by 2007. For the WRHA Regional Pharmacy Program, the Deloitte and Touché External Review reported that approximately 46 FTEs would be required, and approximately one half of those (23) would be pharmacists. An average of 5 additional pharmacists would therefore be needed each year over the next 4 to 5 years to achieve this goal. The total number of pharmacists needed each year would therefore be approximately 20 (15 for turnover replacement and 5 for new positions each year).

It is hoped that the recruitment and retention steps taken to date will be maintained, and that vacancies will be held at their historical levels of 2% to 3%. The ability to achieve this will depend on many external factors that are difficult to predict with any certainty, such as whether the demand for pharmacists in the Internet Pharmacy sector will increase, decrease, or remain the same.

D. Consultations with Stakeholders and ABC Team Methodology

Extensive consultations have taken place with staff pharmacists, unions, pharmacy managers, Senior Management of the WRHA and its facilities, and government agencies. A working group, made up of government and regional health authority representatives, has



formulated a provincial pharmacist manpower strategy for the public sector, which closely mirrors the WRHA’s recruitment and retention plan. In addition, another government/private sector/public sector working group has been developing strategies for increasing the numbers of foreign-trained pharmacy graduates that become licensed to practice in Manitoba.

The ABC Regional Pharmacy Project Team reviewed relevant information including:

• Pharmacy Recruitment and Retention Plan. Prepared by Kevin

Hall, March 2003. • Recruitment and Retention Plans for Allied Health disciplines

including Physiotherapy, Audiology, and Respiratory Therapy. • WRHA Allied Health Recruitment Tuition Relief Allocation Proposal • Relevant Resources (See Appendix 1)

E. Plan for Recruitment and Retention

Recommendations Applicable To All Pharmacy Regional Program Staff

#13 Green

It is recommended that the following initiatives be implemented to support the recruitment and retention of all pharmacy staff:

• Encourage the recruitment and retention of staff of aboriginal

background. • Maintain competitive wages. • Provide flexible work hours. • Implement initiatives to create a quality work life for all staff. • Expand the role of the pharmacy technician. • Develop a fair and equitable education plan for all regional

pharmacy employees. • Provide opportunities for, and reward participation in, advanced

education programs. • Provide adequate time to participate in projects, research, etc. • Develop strategies to encourage women to increase their

participation in the workforce and in the area of management (flexible hours, daycare, etc.)



• Ensure manageable workloads by increasing staff to the levels identified in the External Review.

• Provide career laddering opportunities for all staff. • Acknowledge staff contributions, by providing appropriate reward

and recognition opportunities. • Address issues around inadequacy of workplaces, including

problems with facilities and equipment. • Improve the use of technology as a method of improving the quality

of work life. Examples include Pyxis implementation, ability to access patient information, etc.

• Provide mechanisms to involve staff in decision-making. • Develop a work culture that is friendly, team focused, and

supportive. • Provide adequate management support, as good leadership is

essential for creating a work life conducive to recruitment and retention.

• Provide adequate resources to support student placements. • Provide positive student experiences during their placement.

#14 Red

Provide a $250 educational allotment per employee per year as part of the Regional Pharmacy Program’s budget. Education funds need to be managed as part of the Regional Pharmacy Program to ensure that the allocation of resources is in the best interests of the region. Recommendations Applicable to Pharmacists #15 Green Continue to participate in job fairs, particularly those in Saskatchewan and Manitoba. #16 Green Consider the employment of foreign-trained pharmacists, on a case-by-case basis, if the candidate has a current license to practice in Manitoba or is immediately eligible for license to practice.



#17 Red Continue with tuition relief/return of service agreements. Based on current projections, 10-15 contracts would need to be available annually. #18 Green Continue to fund moving expenses for new pharmacist recruits. #19 Green Advocate for increased enrollment at the University of Manitoba. #20 Green Continue the WRHA hospital pharmacy residency program. #21 Red Increase pharmacy residency stipends to $40,000 per resident, in order to be competitive with other Canadian residency programs. #22 Green Develop a system to enable the sharing of clinical practice experiences and expertise across the region. #23 Green Provide a mentorship support system for pharmacists in the early stages of developing their clinical practice role. #24 Red Increase clinical time. The goal of the Regional Pharmacy Program is to achieve 60% clinical practice for all pharmacists.



#25 Yellow Implement a comprehensive regional vacancy management strategy to insure that there is an equitable distribution of pharmacist manpower within the region. #26 Yellow Enable the region to use pharmacists staffing budgets as a regional resource, so that staff can be deployed as required to manage pharmacist vacancies, support training of new staff from other sites, etc. Recommendation Applicable to Pharmacy Technicians #27 Yellow Improve ability to provide relief coverage for technicians. The development of a casual pool may be beneficial. Summary Overall the region needs to have a more proactive, responsive plan to deal with work life issues impacting workers. The region must have a commitment to deal with issues before crises develop. To ensure this is possible, site managers must have adequate support. There is a need to continue to have a forum for concerns, excellence in management, and power to affect change. The implementation of full time managers will aid in staff retention. Responsibility for implementing these initiatives, following their funding approval by the WRHA, would rest with the Regional Pharmacy Program’s management team.



F. Financial Implications

Annual Financial Implications

Current Annual

Expenditures

Recommended Annual

Expenditures Difference

Participation in Job Fairs $5,000 $5,000 0

Tuition Relief (current 8, increase to 15)

$80,000 $150,000 $70,000

Education Support ($250 x 300 employees)

$75,000 $75,000

Moving Expenses $5,000 $7,500 $2,500

Employment Opportunities for Students (current 14, increase to 22)

$60,000 $95,000 $35,000

Residency Stipend (current is $20,000 x 4, increase to $40,000 x 4)

$80,000 $160,000 $80,000

Total Annual Cost $230,000 $492,500 $262,500

The costs identified above reflect annual costs and the need for tuition relief would be reassessed annually based on vacancy rates. Responsibility for implementing these initiatives, following funding approval by the WRHA, would rest with the Regional Pharmacy Program’s management team.

G. Evaluation

Evaluation will focus on vacancy rates and recruitment rates. The goal of the Regional Pharmacy Recruitment and Retention plan is to achieve vacancy rates that are 3%, or below on an annual basis and a recruitment rate of 20 pharmacists annually. The Regional Pharmacy Program will monitor vacancy rates, with the WRHA Senior Management ultimately having the final responsibility for insuring that this target is met.



4. Drug Distribution This section of the report will focus on the phase of the ABC project related to drug distribution systems for the Pharmacy Regional Program and the resources required to support a regionalized approach to drug distribution. In regards to drug distribution within the WRHA, the External Review conducted by Deloitte and Touché identified that: • More efficient drug distribution processes within the pharmacy program

could free up pharmacist resources and allow them to be redirected from drug distribution to clinical roles.

• At some sites, nursing staff spend considerable time ordering, stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems.

To help address these issues, one of the objectives given to the ABC Regional Pharmacy Project Team was to develop a regional approach for pharmacy services that would include providing all sites with a safe, effective, and efficient drug distribution system. This section of the report provides support for the current drug distribution efforts and makes additional recommendations that the Project Team identified as being necessary to achieve this objective. A. Drug Distribution Overview

The Regional Pharmacy Program is responsible for the distribution of drugs and the provision of professional services that ensure the safe, therapeutically effective, and cost-effective use of drugs within all WRHA facilities. There is over 300 staff at 9 sites with shared responsibility for about $43 million of drugs. Continued emphasis is being placed on safety in health care with medication safety being one of the primary elements. The final report of the National Steering Committee on Patient Safety in Canadian Healthcare recommended the implementation of system changes that have a demonstrated ability to improve patient safety, an example of which is a unit-dose medication system.2 The Canadian Society of



Hospital Pharmacists (CSHP) endorses the use of Unit-Dose/Intravenous (IV) Admixture systems as the system of choice for drug distribution as a method of decreasing medication-related adverse events. CSHP identified that automated dispensing systems such as drug storage devices or cabinets that electronically dispense medications can improve efficiency as well as decreasing medication-related adverse events.

B. Drug Distribution - Standards and Goals

Pharmacy Regional Practice Model

The overall goals for the WRHA Pharmacy Practice Model are to focus on medication safety and to maximize the clinical role of pharmacists so that patients derive full benefit of the pharmacists’ involvement in their care. In order to achieve that goal, pharmacy service infrastructure must be consistently in place at all facilities including a robust pharmacy information system and modern, safe, efficient and reliable drug distribution system that free pharmacist time for clinical activities.

Drug Distribution Systems

The Unit Dose/IV Admixture drug distribution system is widely recognized and endorsed as the drug distribution system of choice for hospitals. This system is safer for the patient, more efficient and economical, and facilitates more effective use of human resources.

Unit Dose/IV Admixture Systems have the following significant advantages as outlined by the Canadian Society of Hospital Pharmacists’ standards statement.13

1. Reduced incidence of medication errors 2. Decrease in medication related activities for Nursing 3. More efficient use of Pharmacy and Nursing personnel 4. Improved drug monitoring and drug use control 5. Reduced Pharmacy inventories 6. Reduced wastage and pilferage 7. Increased adaptability to computerized procedures 8. Improved job satisfaction for health care professionals



Accordingly, the WRHA Pharmacy Program has set goals and objectives for the drug distribution systems at all facilities to achieve efficiencies and common standards of service delivery, with the Unit Dose/IV Admixture system as the fundamental core.

The regional goals for drug distribution systems include: 1. Professional Practice Standards

Drug distribution systems need to be consistent with accepted standards of practice across the nation to meet recommendations outlined by the Canadian Society of Hospital Pharmacists.

2. Improved Efficiency and Consistent Standard of Service

Delivery

Regional pharmacy practice model development is dependent on common systems and technologies to support the model. The goal is to facilitate the implementation of a consistent, recognized standard in drug distribution systems i.e. unit dose and IV admixture services. By doing so, in addition to the inherent safety and cost benefits, the clinical role of the pharmacist in patient care is maximized. The goal is to enhance unit dose and IV admixture services within the WRHA to maximize the benefits related to medication safety, support for nursing, increased time for pharmacist clinical activities, and efficient use of human resources. The standards for unit dose are well established in hospital practice, nationally and internationally.

3. Technology and Pharmacy Technicians

Another goal is to increase the use of technology and to enhance the role of pharmacy technicians to provide more clinical time for pharmacists. These goals are strongly supported by pharmacy literature to improve quality of care and to contain costs.

4. Centralization/Sharing

Another goal is to examine the degree to which centralization or sharing of tasks can assist in deriving efficiencies and costs



savings in the system e.g. unit dose prepacking, batch compounding of IV doses, etc.

5. Appropriate Use of Human Resources

Support for Nursing

The Deloitte and Touché External Review identified that at some sites, nursing staff spend considerable time ordering, stocking and preparing medications as a result of inadequacies in the existing drug distribution systems. WRHA Pharmacy initiatives aimed at expanded provision of unit-dose and automation of the drug distribution systems, where possible, should assist greatly in relieving nurses of current time consuming medication-related activities. Expanded IV Admixture services provided by pharmacy will significantly reduce medication preparation time for nurses and improve the safety of IV Admixture preparation. ABC Project 2.3 – Care Delivery and Staffing surveyed sites in the WRHA to assist with the redesign of nursing roles within the region. The enablers identified included pharmacy unit dose, Pyxis, and CIVA (centralized IV admixtures). Support for the Pharmacist’s Clinical Role WRHA Pharmacy drug distribution system initiatives are focused on maximizing the pharmacists’ clinical roles, which in turn greatly benefits patient care as documented in numerous studies. By optimizing the use of technology and expanding the pharmacy technicians’ role, pharmacist time is released for clinical activities, e.g. prospective review of drug orders, allergy and dose checks, drug interactions, problem resolution, order entry, drug monitoring, and chart review. Such clinical activities also include significant support to the nurses and physicians through easy access to drug information and active involvement of the pharmacist in therapeutic decisions on the patient care units.

Role of Pharmacy Technicians

Pharmacy Technicians fulfill an important role in drug distribution systems by performing the technical aspects of dispensing,



compounding, sterile product preparation, repackaging drugs, stocking of narcotic and non-narcotic ward stock drugs, stocking of Pyxis cabinets, filling of unit dose carts, and inventory management.

Pharmacist functions in the drug distribution system are increasingly being delegated to Pharmacy Technicians to free pharmacists for a more direct patient care role. Tech Check Tech Programs have been implemented at all WRHA acute care facilities to some degree. The Tech Check Tech process involves technicians checking technicians for certain tasks instead of pharmacist checks. Appropriate training, accompanied by appropriate policies and procedures, supports Pharmacy Technicians in taking on a major role in the drug distribution operation. Pharmacy Technicians are also increasingly supporting the clinical role of pharmacists at many sites, for example running needed reports on patients, basic lab data gathering, and literature searches. The Regional Pharmacy Program continues to pursue other opportunities for expanding the role of technicians. It is well recognized that increased pharmacy technician staffing results in increased clinical pharmacist staffing.14 Bond et al observed that as the number of pharmacy technicians increased in US hospitals, the number of medication errors decreased.15

C. Drug Distribution Systems Initiatives a. Automated Unit Dose Drug Distribution Systems (Pyxis)

Pyxis is the automated unit dose drug distribution system of choice for WRHA acute care facilities. It has been implemented at CH (1999), SBGH (2000), and HSC (2002). It has also been implemented at RHC, a long-term care facility within the WRHA (1999).

At present VGH, SOGH, GGH, and HSC intensive care units (adult and pediatric) and HSC PsychHealth currently use manual unit-dose cart-fill. A request for capital funding was submitted (2001) to enable Pyxis/Cerner implementation at VGH.



Recommendations #28 Green That funding for Pyxis and Cerner implementation at VGH remain as a high priority in the Regional Pharmacy Business Plan and proceed once funding is available. #29 Green That funding for Pyxis and Cerner implementation at GGH is included in the next Regional Pharmacy Program business plan, given that the GGH has recently made the decision to pursue Pyxis and Cerner implementation at that site. The Regional Pharmacy Program will continue to explore options for automation at SOGH to ensure that a comparable system is in place. Due to unit configurations Pyxis is not being recommended at this time. At this time manual unit dose cart fill will likely remain in place at HSC intensive care units (adult and pediatric) and HSC PsychHealth for the foreseeable future due to unit configurations and service delivery models.

Benefits • Automated unit dose drug distribution systems significantly free

up pharmacist time for clinical care • More efficient use of Pharmacy and Nursing personnel • Reduction in medication-related adverse events

b. Admixture Services The extent of IV admixture services varies among WRHA facilities. HSC and SBGH have the most extensive programs. All sites require additional resources and renovations in order to expand current IV Admixture services.



Recommendation #30 Red That resources be made available to support expansion of IV admixture services at all sites. It is further recommended that the WRHA continue to explore opportunities to develop a centralized system for IV admixture. Benefits • A higher product preparation standard • Enhanced patient safety • Decrease in nursing workload as a result of not having to mix

preparations on the ward

c. Pharmacy Technician Role Expansion Tech Check Tech Programs have been implemented at all acute care facilities to some degree. Recommendations #31 Green Continue with the steps required to expand Tech Check Tech and pursue other opportunities for expanding the role of technicians. This will include advocacy on the part of senior management for enabling changes to the provincial pharmaceutical act. #32 Green That the need for an increased number of technicians, as well as increased educational resources to ensure adequate training and quality assurance programs, be given a high priority when ABC funding becomes available for reinvestment in pharmacy services. Benefits • Increased pharmacist time for clinical care • Improved job satisfaction for pharmacists and pharmacy

technicians



• More efficient use of human resources leading to higher technician to pharmacist ratios and lower overall costs

d. Pharmacy Information Systems

The implementation of a regional, integrated pharmacy information system is an objective of the WRHA Pharmacy Program. It has been accepted and included in the WRHA Regional Health Plan. Such a system is an essential component of Pharmacy’s day-to-day operation, e.g. drug distribution, inventory management, and clinical role. Recommendation #33 Green That implementation of the regional pharmacy information system proceeds as funding becomes available. Priority should be given to the sites that currently have the oldest and least effective pharmacy information systems, i.e. VGH and GGH. Automation of the drug distribution systems (Pyxis) at those two sites is dependent on these upgrades. Benefits • Provision of a modern, robust system to meet Pharmacy’s

service provision needs • Centralized support and maintenance of system and data bases • Ability to extract and share information • Ability to reduce the number of interfaces and problems

between new technologies and applications and stream line support

• More efficient problem solving within and between facilities • Increased leverage with the vendor for software enhancements • Increased purchasing power for the hospitals • Ability to assist with the implementation of reforms within the

health care system • Ability for staff to move between sites without the need to retrain

them on new systems



e. Automated Dispensing Technology for Long Term Care – Deer Lodge Centre (DLC) and Misericordia Health Centre (MHC)

Current system is 32-day blister card system, which is labour intensive for the pharmacy department. A proposal and capital funding request was submitted in April 2002 for the implementation of automated repackaging technology. Recommendation #34 Green That an automated dispensing/packaging system for the long-term care beds at the DLC and MHC be implemented, once funding becomes available. Benefits • Automated drug distribution systems significantly free up

pharmacist time for clinical care • More efficient use of Pharmacy and Nursing personnel • Improved inventory management

f. Centralized Unit-Dose Packaging Unit-Dose Packaging is presently being done at individual sites. Sites are encountering difficulty accommodating the packaging due to workload and space issues. The ATC-212 packaging machines in use at GGH, SOGH, and VGH will no longer be supported by the manufacturer after 2006. Recommendation #35 Red That the WRHA support the implementation of centralized unit-dose packaging for acute care sites, by approving the request for equipment funding. A system that is able to support the entire region is the ideal. Procurement of a regional automated packaging machine is essential as the existing ATC-212 drug packaging systems will no



longer be supported by the manufacturer after 2006. The machines will have to be replaced at GGH, SOGH, and VGH. Benefits • Centralization affords efficiencies in packaging procedures and

workload • Improved inventory management • Improved quality control The Pharmacy Program is committed to the development and implementation of a Regional System for Drug Distribution. This will increase standardization and automation to ensure a higher level of patient safety across the region as well as enabling an increased clinical role for pharmacists.

D. Consultations with Stakeholders and ABC Team

Methodology

The ABC project team reviewed and discussed the current regional plan related to drug distribution. The Regional Manager responsible for this area has extensively consulted with other regions and within the WRHA to enable the development of a comprehensive regional plan related to drug distribution.

The ABC Regional Pharmacy Project Team reviewed relevant information including:

• The WRHA Pharmacy Regional Program’s 3 Year Integrated

Business Plan for 2004-2007.16 • Regional Drug Distribution System Initiatives, July 2003. • Regional Drug Distribution System Initiatives-Status Report for

ABC Pharmacy Project May 2003 (revised February 2004). • Relevant Resources (See Appendix 1).

E. Financial Implications

Funding submissions regarding drug distribution systems have been included as part of the Pharmacy Business Plan 2004-2007, except for expansion of IV Admixture services as described in Initiative #b.



There are no additional financial implications based on the work of the team. IV Admixture expansions or centralization initiatives for IV Admixture require detailed proposals not attempted by the team.

Responsibility for implementing the recommended computer and drug distribution systems, following funding approval by the WRHA, would rest with the Regional Pharmacy Program’s management team.

F. Evaluation

Delivery of the objectives identified in regards to drug distribution, will result in:

• Increased satisfaction, on the part of nursing, medical, and

pharmacy staff with the drug distribution system provided by the pharmacy program.

• Safe, effective, efficient, and standardized drug distribution systems in place at all sites across the region. Quality indicators for drug distribution systems such as medication occurrence monitoring, down time procedures, etc.

• Review and refinement of drug distribution system usage – current and proposed.

The benefits of implementing the initiatives associated with drug distribution include improving patient safety, increasing quality of care, more appropriate use of human resources, more consistent standards to practice, and improved ability to recruit and retain pharmacists. The overall goals of the Regional Pharmacy Plan in regards to drug distribution are to ensure a sustainable, consistent, and high standard of service across the region. This will result in increased safety for patients, more effective use of automated packaging equipment, and more efficient utilization of staff.



5. Clinical Pharmacist Support This section of the report will focus on the phase of the ABC project related to Clinical Pharmacist Support for the Pharmacy Regional Program and the resources required to support a regionalized approach to Clinical Pharmacist Support. In regards to Clinical Pharmacist Support within the WRHA, the External Review conducted by Deloitte and Touché identified that: • There is an increasing demand for clinical pharmacist support. • More efficient drug distribution processes within the pharmacy program

could free up pharmacist resources and allow them to be redirected from drug distribution to clinical roles.

• At some sites, nursing staff spend considerable time ordering, stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems.

To help address these issues, one of the objectives given to the ABC Regional Pharmacy Project Team was to develop a regional approach for pharmacy services that would include providing all sites with safe and effective level of Clinical Pharmacist Support. The project team will examine and develop a regional approach for Clinical Pharmacist Support. Achievement of these goals will result in desired clinical outcomes and improved quality of life for the patients that are served as well as effective utilization of human and material resources. Increasing the clinical support role for pharmacists will result in increased satisfaction, on the part of nursing, medical, and pharmacy staff, with the clinical services provided by the pharmacy program, and improved collaboration between nursing and pharmacy. This report provides support for the Regional Pharmacy Program’s current Clinical Pharmacist Support efforts and makes additional recommendations that the Project Team identified as being necessary to achieve this objective. A. Clinical Pharmacist Overview

The Canadian Society of Hospital Pharmacists (CSHP) advocates strongly for expanding the clinical pharmacy role for hospital



pharmacists.2 Pharmacists can work directly with other health care professionals to optimize patient outcomes, decrease medication related costs, decrease the number of adverse drug events and medication related errors, improve management of disease, decrease need for health services, and improve patient care overall. The Institute of Medicine (IOM) Medication Safety provides a variety of Pharmacy related recommendations including participation on patient care rounds and providing drug information to health care professionals.17 To quote the IOM report “As the major resource for drug information, pharmacists are much more valuable to the patient care team if they are physically present at the time decisions are being made and orders are being written. Such participation is usually well received by nurses and doctors, and it has been shown to significantly reduce serious medication errors.” It is well established within the literature that increased clinical pharmacy staffing is associated with decreased patient mortality, decreased drug costs per occupied bed, overall reduced cost of care, shorter length of stay, and decreased drug errors.14, 15, 18 Within the nine sites of the WRHA Pharmacy Program, direct patient care pharmacy services are diverse and not consistently provided. Clinical Pharmacy Services within the nine sites have evolved via different practice models and prioritization of activities. The differences in models and activities are due in part to differences in patient populations served (e.g. acute care vs. long term care), resources, infrastructure (e.g. type of drug distribution system, number and utilization of technicians), priorities and philosophy. It has been identified that a standardized practice model and associated practice standards would help to provide consistent pharmacy services within the WRHA and would help individual pharmacists to provide a standardized approach to direct patient care pharmacy activities. The specific processes involved with the implementation of the practice model are dependent on a number of factors. Specific parts of the model are implemented based on the site infrastructure, access to patient information as well as the existing knowledge and skills of pharmacists. Concurrent staff development is essential. In addition, ongoing review and revision of



infrastructure is essential to maximize the time pharmacists’ have available for direct patient care activities.

B. Pharmacy Regional Model for Clinical Pharmacist Support All hospitals within the WRHA have completed The Institute for Safe Medication Practices’ “Medication System Self Assessment Survey”. The results highlight a number of areas where medication safety improvement could be realized. Initiatives related to Clinical Pharmacist Support that are being considered for implementation include: improved access to comprehensive patient information at the point of care, improved access to comprehensive drug information at the point of care, improved access to clinical pharmacy services at the point of care, and implementation of strategies to increase patient’s knowledge of their drug therapy and their involvement in the management of their drug therapy. Part of the 2004-2007 Regional Pharmacy Program’s business plan is to implement a standardized Pharmacy Practice Model, which increases the direct patient care role of pharmacists within the WRHA. The practice model that the WRHA is striving to achieve is based in part on: WRHA pharmacist focus group sessions, literature, discussions with pharmacy practice leaders at selected sites across North America, Holland-Nimmo practice change model, and the CSHP White Paper on the Establishment and Elaboration of Clinical Pharmacy Services.19, 20 A working group of pharmacists within the Internal Medicine practice area has been established to develop pharmacy practice expectations. The team has collated existing site-specific policies regarding the role and practice expectations of pharmacists, collated existing “clinical tools” within the WRHA Pharmacy Program, developed a list of core (must do) and desirable (should do) activities, and developed a draft policy procedure regarding the pharmacist expectations. The practice expectations provide guidelines for activities to be performed under full-staffed and short-staffed (pharmacist) conditions. The practice expectations provide a tool for pharmacists to self-evaluate the quality of the service they



provide, and identify opportunities for personal and/or staff development. The practice expectations are viewed as the type of practice pharmacists’ strive to attain. Rollout of the practice expectations to a ll acute care sites is expected this summer. During the fall, selected practice areas (e.g. medicine, surgery) will meet to refine the practice expectations to the needs of the specific practice area. Using this initial document as a framework, other practice areas will develop practice expectations and the Regional Pharmacy Program will develop a communication and rollout plan. The practice expectations will evolve to performance based assessment over the next several years.

Framework for Clinical Pharmacist Support Several aspects are central to the practice model. These include: • The majority of pharmacists’ time (> 80%) is related to decentralized

direct patient care services. • Progression of the model and practice standards is based on the

infrastructure/support structure at the specific sites. Constant review of the infrastructure is required to advance the practice model and standards.

• All WRHA sites will have a common basic core set of activities. Some activities will be altered (added, deleted, increase/decrease time utilized) based on the patient population.

• Specific activities within the model/practice standards are maximized based on the existing infrastructure. Suggested sequencing of activities for the model/practice standards is described below. Progression of the model is based in part on CSHP white paper.19

• Three components of Holland-Nimmo practice change model are present:20 • Environment in which there is an opportunity to practice new

activities • Available training • Motivated staff



Recommendation #36 Red That the WRHA Regional Pharmacy Program strive to achieve Clinical Pharmacy Support Level 2 and Level 3, as described below and support the further development and implementation of clinical practice standards. It is recommended that the WRHA support this initiative by providing increased levels of staffing and improved drug distribution systems outlined in Sections 4 and 6 of this report. Proposed Levels of Clinical Pharmacy Support

Level 1: Drug Order Review

This is not direct patient care activity per se, but is a starting point for more direct patient pharmacotherapy monitoring.

The basic elements are:

• Central monitoring of medication orders • Some selective monitoring

• Verify dosing of select agents based on calculated creatinine clearance in all patients OR

• Verify dosing of any agent based on age >75, patient receiving medication of a type or in a dose that suggests renal dysfunction

Level 2: Selective Patient Pharmacotherapy Monitoring

• Monitoring on patient care units

• Progression from partial shifts to complete shifts 5-7 days per week

• Patient:pharmacist ratio approx. 60-120:1 • Selective monitoring (includes identify DRP, prepare plan,

monitoring (efficacy/toxicity), PK) • Some examples of selective monitoring include:

• Narrow therapeutic agents • Interacting agents • Disease states which predispose to toxicity or altered

efficacy



• Use of Cerner Discern to help select patients • Specific patient consults (e.g. aminoglycoside dosing)

Level 3: Comprehensive Patient Pharmacotherapy Monitoring

• Pharmacotherapy monitoring on all patient care units • Patient:pharmacist ratio approx. 30-90:1 (based on patient care

unit workload) • Rounding with patient care team on selected units (e.g. ICU,

medicine) • Extensive selected patient monitoring • Education of pharmacy students • Selective patient interview • Selective patient counseling • Selective continuity of care • Other activities as per practice model

C. Regional Initiatives For Enhancing the Level of

Clinical Pharmacist Support Provided to Patients

The enhancement of the Pharmacist Clinical Role is an integral part of the overall Regional Pharmacy Program and cannot be developed in isolation. To enable pharmacists to decentralize and increase their involvement with direct patient care the region must invest in other aspects of the program to free up pharmacists to participate more fully in the area of clinical pharmacy as well as providing the necessary education and support for the program. Enablers for implementation of the pharmacists’ clinical role are critical to the success of this initiative. Pharmacist shortages have impeded the ability to have pharmacists present on patient care units. The External Review recognized that in the Winnipeg region pharmacy staffing is significantly below peers across the country. Increased pharmacy staffing levels across the region are required to implement the proposed Clinical Pharmacist initiative.



Recommendations #37 Red That sufficient pharmacist staffing, as identified in the External Review, be provided to support the clinical, decentralized role of the pharmacist. Pharmacist functions in the drug distribution system are increasingly being delegated to Pharmacy Technicians to free pharmacists for a more direct patient care role. Pharmacy Technicians are also increasingly supporting the clinical role of pharmacists at many sites, for example running needed reports on patients, basic lab data gathering, and literature searches. Bond et al reported that increased pharmacy technician staffing had the greatest association with increased clinical staffing.14 #38 Red That sufficient pharmacy technician staffing, as identified in the External Review, be provided to support the clinical, decentralized role of the pharmacist. The drug distribution system initiatives described in Section 3 of this report, as well as a modern pharmacy information system, are also important enablers of the pharmacists’ clinical role. #39 Green That implementation of the drug distribution systems described in Section 4 of this report, and implementation of a comprehensive regional pharmacy information system at all sites, be given a high priority in capital planning for the region. Another highly desirable support for clinical pharmacy practice would be better access to patient information. This would include easy access to computerized pharmacy records from previous admissions at the same facility, as well as easy, rapid access to the same information from past admissions at other facilities. It would also be desirable if technology permitted pharmacists to collect and document patient information in a consistent format that could easily be shared with other pharmacists who become involved in the care of that same patient.



#40 Green That the Regional Pharmacy Program continue its efforts to improve access to relevant patient information and drug information at the point of care. As described above, the WRHA Regional Pharmacy Program has developed practice expectations in the area of Internal Medicine and will use this model to develop similar guidelines for other areas of practice. A further enabler for the enhancement of clinical pharmacist support has been the development, by the Regional Pharmacy Program, of a “career ladder” for pharmacists. (Appendix 5 - Regional Pharmacy Program Career Ladder) The career ladder serves a number of purposes. Its initial purpose has been to serve as a tool to motivate pharmacists to improve their clinical practice skills and to set goals for their own personal development. The career ladder also defines the highest step on the ladder (Step 5) as a “clinical leader”. The ABC Pharmacy Project Team endorses the concept that a cadre of such individuals is required within the region to act as clinical mentors, instructors, and practice leaders. As earlier mentioned, it is envisioned that “clinical leaders” will fulfill much of the role once envisioned for “clinical coordinators/pharmaceutical care coordinators”. It is hoped that eventually salary scales may be developed that are aligned with the career ladder, and which would serve to encourage pharmacists to improve their practice skills and increase their participation in teaching, publishing and research activities. #41 Green That the Regional Pharmacy Program be encouraged to continue with the development and implementation of the career ladder for pharmacists, and its use as a means of reward and recognition be further explored with Human Resources and the applicable collective bargaining units. The Regional Pharmacy Program will continue to pursue the development and refinement of the Pharmacy Clinical Leader position. #42 Green That education and development programs for staff pharmacists be recognized as a necessary support for the successful implementation of the proposed career ladder. The creation of an



educational support service within the WRHA’s Regional Pharmacy Program, as proposed in the Program’s Business Plan, is recommended.16 Several pilot proposals for extending the clinical role of the pharmacists to non-hospital settings have recently been developed by the Regional Pharmacy Program. The first of these was a proposal for the delivery of pharmaceutical care by a pharmacist within the River East Community Access Centre Primary Care Clinic and within the Home Care setting in the same geographical area. Involvement of pharmacists in the primary care practice setting has demonstrated improvement in the cost-effectiveness of drug therapy, improved patient satisfaction, and improved patient quality of life. A WRHA Community Access Centre primary care clinic and the home care setting are ideal areas to develop a model for pharmacist involvement. A pilot project has also been proposed to establish a model for the delivery of pharmaceutical care within the setting of private physicians’ in the River East community area. #43 Green That the Regional Pharmacy Program continues to pursue opportunities for extending clinical pharmacist support throughout the continuum of care.

D. Consultations with Stakeholders and ABC Team Methodology The ABC project team reviewed and discussed the current regional plan related to Clinical Pharmacist Support. The Regional Manager responsible for this area has extensively consulted with other regions and within the WRHA to enable the development of a comprehensive regional plan related to Clinical Pharmacist Support. The ABC Regional Pharmacy Project Team reviewed relevant information including: • The WRHA Pharmacy Regional Program 3 Year Integrated

Business Plan 2004-2007.16 • Resource List (See Appendix 1)



E. Financial Implications Funding submissions regarding Clinical Pharmacist Support have been included as part of the Pharmacy Business Plan 2004-2007. There are no additional financial implications based on the work of the team. However, the infrastructure upgrades to drug distribution systems and pharmacy information systems, for which funding submissions already exist in the Regional Pharmacy Program’s business plan, are important enablers for the clinical role of pharmacists. Responsibility for implementing the Clinical Pharmacist Support program, following funding approval by the WRHA, would rest with the Regional Pharmacy Program’s management team.

F. Evaluation Delivery of the objectives identified in regards to Clinical Pharmacist Support, will result in: • An increase in the clinical support role of pharmacists • Increased satisfaction, on the part of nursing, medical, and

pharmacy staff, with the clinical services provided by the pharmacy program

• Improved collaboration between nursing and pharmacy The benefits of implementing the initiatives associated with Clinical Pharmacist Support include improving patient safety, increasing quality of care, more appropriate use of human resources, more consistent standards to practice, improved ability to recruit and retain pharmacists, decreased drug costs, and improved patient outcomes.



6. Adequate Pharmacy Staffing Levels This section of the report will focus on the phase of the ABC project related to the provision of Adequate Pharmacy Staffing Levels for the Pharmacy Regional Program. In regards to Pharmacy Staffing Levels within the WRHA, the External Review conducted by Deloitte and Touché identified that: • Pharmacy staffing levels at most WRHA facilities are below Canadian

peer levels. • There is a need to make manpower investments at acute care sites.

Short-term/immediate reinvestment is recommended at SBGH. • A shortage of pharmacists exists throughout the health care system. • There is an increasing demand for clinical pharmacist support. • At some sites, nursing staff spend considerable time ordering,

stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems.

To help address these issues, one of the objectives given to the ABC Regional Pharmacy Project Team was to develop a regional approach for pharmacy services. This would include a staffing plan, based on the new service delivery model that would ensure that pharmacy staffing levels are adequate to support the provision of quality pharmacy services at all sites. Reinvestment in pharmacy services at SBGH would be the first priority. Achievement of this goal will result in pharmacy staffing levels that will be in line with peers, improved staff retention rates, and an increase in pharmacy paid hours per adjusted patient day. The provision of adequate staffing across the region will result in improved patient safety, desired clinical outcomes and improved quality of life for the patients that are served as well as effective utilization of human and material resources. Adequate staffing will allow for an increase in the clinical support role for pharmacists, which will result in increased satisfaction, on the part of nursing, medical, and pharmacy staff and improved collaboration between nursing and pharmacy. This report will provide a proposed plan and recommendations in regards to staffing. As a result of financial constraints across the region the team



has deferred developing an in depth staffing plan until such time as reinvestment is likely to occur, and the extent of reinvestment is known. A. Pharmacy Staffing Overview

The Deloitte and Touché External Review demonstrated that the WRHA requires 45.2 EFTs in order to be at the 50% percentile staffing levels of Canadian peers. In the 2004-2007 Business Plan the Pharmacy Regional Program has identified the need to have pharmacy staffing and service levels that compare favorably to benchmarks for similar Canadian health care organizations.16 The business plan identifies the importance of attracting and retaining pharmacists and pharmacy technicians to enable implementation of the pharmacy initiatives. There is increasing competition from the private sector in the area of pharmacist recruitment. The current situation of under staffing has severely tested the Pharmacy Regional Program’s ability to provide existing services, and prevents any expansion of services. It also limits the Pharmacy Program’s ability to provide clinical jobs that will attract pharmacists into positions in hospitals. This proposed increase in staffing will result in improved work life for staff and a consistent approach to service delivery across the region, as well as enabling the program to implement pharmacy service improvements.

B. Pharmacy Regional Model for Staffing

The External Review recognized that in the Winnipeg region pharmacy staffing is significantly below peers across the country. The Pharmacy Regional Program envisions a future in which staffing overall will compare favorably with peers across the country enabling the region to adequately support existing programs and to implement new initiatives aimed at improving safety and service delivery across the region. Increased pharmacist and pharmacy technician staffing levels across the region are required to implement the proposed changes



to the Pharmacy Practice Model as described earlier in this report. Pharmacist staffing must be adequate to support a more decentralized role, which has been strongly associated with improved safety, better outcomes, and cost containment. Pharmacist shortages have impeded the ability to have pharmacists present on patient care units.

C. Regional Staffing Initiatives

The Pharmacy Regional Program continues to aggressively recruit pharmacists and aims for a recruitment rate of 15 pharmacists per year to replace staff that vacates existing positions. The region offers a residency program in an effort to attract and train pharmacists for the WRHA. Once funding is available the Regional Pharmacy Management group, will review information from benchmarks across the country and review staff distribution and staff mix across each site, program, and at the regional level to best determine how staffing increments should be allocated. Recommendations #44 Green That agreement in principle be affirmed to increase pharmacy staffing to benchmark levels over the next five years, commensurate with availability of resources. #45 Green That the Steering Committee endorse the ABC Regional Pharmacy Model team’s proposed plan to defer staffing allocation until funding becomes available. The Regional Pharmacy Program will then complete an in-depth assessment, analysis, and consultation when information regarding the availability and amount of funding for reinvestment is known. Once funding is secured, the Regional Pharmacy Management group will assess needs across the region, provide up to date recommendations, and proceed to implementation.



D. Consultations with Stakeholders and ABC Team Methodology The ABC project team reviewed the Deloitte and Touché review and is in agreement with the identification of inadequate staffing across the region. Once funding is imminent the Regional Pharmacy Management group will consult with sites, programs, and community areas to assist in determining the plan for staff allocation. The team has discussed the approach to staffing adjustments and in consideration of the current financial constraints across the region the team has deferred completing an in depth study to determine specific recommendations until such time as reinvestment is likely to occur. Likely target areas for reinvestment include Bone Marrow Transplant, establishment of satellite pharmacy services to NICU at SBGH, an increase in pediatric staffing at HSC, and regional educational services. However, the situation will require an in depth assessment at a future date, closer to an actual implementation time, when the pharmacy priorities of the region may well have changed.

E. Financial Implications

A financial plan was submitted to the PMO outlining the finances associated with increased staffing. (See Appendix 6 - ABC Staffing Adjustment Financial Plan) The proposed staffing plan would include both pharmacists and pharmacy technicians. Responsibility for implementing the staffing adjustments, following funding approval by the WRHA, would rest with the Regional Pharmacy Program’s management team.

F. Evaluation

Delivery of the objectives identified in regards to Adequate Pharmacy Staffing Levels, will result in: • An increase in the clinical support role of pharmacists



• Increased pharmacy staff satisfaction • Improved safety across the region • A consistent approach to service delivery across the region

The benefits of providing additional pharmacy staff across the region include improving patient safety, increasing quality of care, more appropriate use of human resources, more consistent standards to practice, improved ability to recruit and retain pharmacists, decreased drug costs, and improved patient outcomes.



7. Communication Plan Once approval from steering committee is obtained presentations regarding the proposed Regional Pharmacy Model, the potential impact of the changes will be communicated to the: • Site CEOs • Clinical Program Teams • Site-based leadership groups • Site Pharmacy Managers • Front line staff The purpose of the presentations will be to reassure, inform, involve, and to seek feedback and support.



8. ABC 6.2 Pharmacy Regional Model Team Members

Project Sponsors

Role Name Title

Initiative Leader Janet Bjornson Regional Director Allied Health

Executive Sponsor Real Cloutier VP & Chief Allied Health Officer

Project Team

Role Name Title

Project Lead Kevin Hall Regional Director Pharmacy

Team Member Merle Cummings Pharmacy Technician SBGH

Team Member Patrick Fitch Site Pharmacy Manager HSC

Team Member Dr. Patricia Honcharik Clinical Pharmacist HSC – Senior Pharmacist

Team Member Clint Huber Senior Pharmacist CGH

Team Member Lynda Mandzuk Continuing Education Instructor – Nursing SBGH

Team Member Heather Milan Regional Pharmacy Manager Drug Distribution Systems

Team Member Dr. Jodene Wong Clinical Pharmacist VGH

Team Member Daphne Randall Director of Human Resources GGH

Project Manager Susan Gerlach



Appendices

Appendix 1 Resource List

1. WRHA Pharmacy Program Review – Chuck Wilgosh and Jim Hunter, May 17, 2001. 2. Canadian Society of Hospital Pharmacists. Impact of Hospital Pharmacists on

Patient Safety. December 2003.

3. Hospital Pharmacy in Canada Survey Results 2001/2002 – www.lillyhospitalsurvey.ca.

4. Hospital Pharmacy in Canada Survey Results 1996/1997 “Multi-site Healthcare

Organizations – A 90’s Phenomenon” - www.lillyhospitalsurvey.ca.

5. Management Responsibilities, Organizational Structure, and Outcome Targets Proposed for the WHA Regional Pharmacy Service – Kevin Hall, May 1999.

6. Lowe G.S. 2002. “High Quality Healthcare Workplaces: A Vision and Action Plan.”

Hospital Quarterly Summer: 49-56.

7. Cox E.R, Fitzpatrick V. “Pharmacists’ job satisfaction and perceived utilization of skills.” Am J Health-Syst Pharm 1999; Sept 56:1733-1737.

8. MacInnis M., Power B., Cooper J. Environmental Scan of Pharmacy Technicians.

Canadian Pharmacists Association. September 2001.

9. Workforce Supply for Hospitals and Health Systems: Issues and Recommendations. American Hospital Association. January 2001.

10. Peartree Solutions Inc., HRDC, Canadian Pharmacists Association. A Situational

Analysis of Human Resource Issues in the Pharmacy Profession in Canada. July 2001.

11. Knapp K. Pharmacist Workforce Challenges: Exploring Today’s Manpower

Shortages. Cardinal Health Dec 2001.

12. WRHA Allied Health Worklife Survey. February 2003.

13. CSHP, Official Publications, 2001 – Statement on Unit Dose and IV Admixture Drug Distribution.

14. Bond CA, Raehl CL, Franke T. Clinical pharmacist staffing in United States hospitals.

Pharmacotherapy 2002; 22(11): 1489-1499.

15. Bond CA, Raehl CL, Franke T. Medication errors in United States hospitals. Pharmacotherapy 2001; 21 (9): 1023-1036.

16. WRHA Pharmacy 3 Year Integrated Business Plan 2004-2007.



17. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human. Building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, DC: Academy Press; 1999.

18. Bond CA, Raehl CL, Franke T. Interrelationships among mortality rates, drug costs,

total cost of care, and length of stay in United States hospitals: summary and recommendations for clinical pharmacy services a staffing. Pharmacotherapy 2001; 21 (2): 129-141.

19. A White Paper on the Establishment and Elaboration of Clinical Pharmacy Services.

Canadian Society of Hospital Pharmacists, Toronto, Ontario April 1990.

20. Holland RW, Nimmo CM. Transitions, part 1: beyond pharmaceutical care. Am J Health Syst Pharm. 1999 Sep 1;56(17):1758-64.



Appendix 2 Proposed Regional Pharmacy Program Organizational Chart

Site CEOsWRHA Regional

Pharmacy Director

AdministrativeDirector

WRHA

AdministrativeAssistant

Clincal Programs

CGHSite Manager

1.0

GGHSite Manager

1.0

SOGHSite Manager

1.0

VGHSite Manager

1.0

DLCSite Manager

0.5

MHCSite Manager

0.5

RHCSite Manager

0.5

SBGHSite Manager

3.0

HSCSite Manager

3.0

SeniorPharmacists& Site Staff

SeniorPharmacists& Site Staff

SeniorPharmacist &

Site Staff

SeniorPharmacist &

Site Staff

SeniorPharmacist &

Site Staff

SeniorPharmacist &

Site Staff

SeniorPharmacist &

Site StaffSite Staff Site Staff

Regional ManagerPharmacy

Information Services1.0

Regional ManagerDrug Distribution

Systems/Inv. Drugs1.0

Regional ManagerDrug Information/

Drug UseManagementSystems 1.0

Regional ManagerDrug Procurement/Inventory Control

Systems 1.0

Regional ManagerProfessional Practice

Development 0.75

Regional ManagerEducational Services

1.0

Managing information and communication systems

Managing drug distribution systems and investigational drug services

Managing the drug information and drug use management system, coordinates activities of the regional Pharmacy and TherapeuticsCommittees and interacts with the pharmacare program

Manage systems and processes need to optimize the effectiveness and efficiency of pharmaceutical procurement, logistics management and inventory control

Evaluating, planning, implementing and maintaining the practice model and standards for the direct patient care services (pharmaceutical care) that are delivered by the WHA

Evaluating, planning, implementing and maintaining the systems and processes needed to optimize the effectiveness of educational programs

PROPOSED REGIONAL PHARMACY MODELOrganizational Chart



Appendix 3 Regional Pharmacy Managers’ Survey

ABC Pharmacy Project Regional Pharmacy Model

Site/Regional Pharmacy Managers’ Survey

Please circle the best answer and add any comments you might have. 1. To whom do you really report? (i.e. the reality vs. the concept)

My primary reporting relationship is to the:

All

Site

Managers

Regional

Managers

a. Site 5 5 0

b. Region 6 0 6

c. Equally to the site and region 3 3 0

d. Other (please specify) 1 1 0

2. Are your responsibilities to the site and region clearly defined?

All

Site

Managers

Regional

Managers

a. Yes 9 4 5

b. No 6 5 1

3. How well do you believe your existing reporting relationship: (question 3 cont’d on next page)

i. Works for you? All

Site

Managers

Regional

Managers

a. Very Well 6 2 4

b. Satisfactorily 6 4 2

c. Poorly 3 3 0



ii. Works for your site? All

Site

Managers

Regional

Managers

a. Very Well 1 1 0


c. Poorly 2 2 0

d. Not applicable 6 1 5

iii. Works for the regional pharmacy program? All

Site

Managers

Regional

Managers

a. Very well 3 1 2


c. Poorly 3 3 0

4. When there is a conflict between the direction you are receiving from your site and

from the region, how easy is it to work out a satisfactory resolution?

All

Site

Managers

Regional

Managers

a. Very easy 1 1 0

b. Manageable 8 5 3

c. Very difficult to resolve 4 4 0

d. Not applicable 3 0 3

5. If your reporting relationship was to change in a reorganization of the regional pharmacy program, would you prefer a change that:

a. strengthened the reporting relationship of all pharmacy managers to the WRHA’s regional pharmacy program

b. reinforced the reporting relationship of regional pharmacy managers to the region and site pharmacy managers to the site.

c. created a regional pharmacy program that is managed collectively by site and regional pharmacy managers who agree to be bound by decisions of the majority.

All

Site

Managers

Regional

Managers

A 1 1 0

B 7 7 0

C 2 2 0



6. Do you believe that changes are needed to the organizational model for the regional pharmacy program?

All

Site

Managers

Regional

Managers

a. Yes 12 6 6

b. No 3 3 0

7. If you believe that changes are necessary, what form do you believe those changes should take?

• Amalgamate all pharmacy staff as a fully constituted program under direct reporting

relationship and affiliation to the WRHA/Regional Director of Pharmacy, (including having all employees hired by/accountable to one organization, not ten corporate entities as presently occurs!). That is, adopt the model that appears to be working well in most other regional pharmacy programs of this size in Canada e.g., Edmonton, Calgary, etc.

• A truly regionalized Pharmacy Program, with ALL pharmacy staff and budgets reporting to the Regional Program.

• Senior management (above the level of the pharmacy site managers and regional pharmacy managers) must be willing to support their change and be a positive force.

• Increased strength in regional reporting relationship.

• Establish single site managers for those sites that have shared site managers.

• Site Managers manage the pharmacy for WRHA. This is what should be clear to the site and the WRHA Administration “manage” the program. Not the managers group, those farther up.

• Revisit Shared Site Managers role, i.e. eliminate or provide additional supports at sites. Model needs to foster commitment of individual sites to regional vision and objectives.

• More EFT to support drug information for all sites.

8. If changes were made to the organizational model would you prefer a model where:

a. site and regional pharmacy managers participate in decision-making but sites or the region retain the ability to opt out or modify their participation in implementing the decision

b. the WRHA regional pharmacy program makes decision that are binding on the sites and region

c. the site and regional pharmacy managers participate in decision-making, and decisions made by the majority are binding on all sites and the region

All

Site

Managers

Regional

Managers

2 2 0

5 2 3

9 5 4



9. Do you believe that the responsibilities of the site and regional pharmacy managers:

a. are clearly distinct and understood by everyone b. overlap, but the roles of each are understood by everyone c. overlap, and the roles of each are confusing

All

Site

Managers

Regional

Managers

0 0 0

6 5 1

9 4 5

10. For issues where there is overlap between the roles of the site and regional pharmacy

managers, would you prefer a model where:

a. regional pharmacy managers serve as the primary contact with senior management of the site/program, and, in consultation with the site pharmacy manager, take a lead role in addressing site issues that fall within their area of responsibility

b. site pharmacy managers serve as the primary contact and take a lead role in addressing site issues, with the regional pharmacy manager serving in a consultant capacity

c. site and regional pharmacy managers are equally involved in addressing site issues that fall within a regional pharmacy managers portfolio

All

Site

Managers

Regional

Managers

3 2 1

8 7 1

2 4 6



Appendix 4 Regional Pharmacy Model Survey Results – November 2003

Purpose of Survey

s To develop an understanding of the organizational structures in other regions and the strengths and challenges of the current structures.

s To gather information regarding the infrastructure in other regions across the country including reporting structure, staffing patterns, recruitment and retention initiatives, unique site specific activities, and management of site specific challenges of pharmacy.

Regions Surveyed

1. Calgary Health Authority – Steve Long, Director of Pharmacy 2. McGill University Health Centre – Patricia Lefebvre, Director of

Pharmacy 3. Edmonton – Capital Health Authority – Chuck Wilgosh, Former

Director of Pharmacy 4. Saskatoon Health Region – Janet Harding, Director of Pharmacy 5. Halifax – Capital Health Region – Brian Tuttle, Director of Pharmacy 6. Simon Fraser Health Region, B.C. – Bob Nakagawa, Director of

Pharmacy

Overall Summary of Survey Results

I. Regional Structure

All regions reported the following: s Pharmacy structured as a Regional Program s Line reporting and accountability of all pharmacy site

managers and pharmacy staff to Regional Director of Pharmacy.

s All Pharmacy staff employed by Region, except for the Caritas Group in Edmonton

s Single Region Board except Caritas Group in Edmonton and St. Paul’s Hospital in Saskatoon

s Regional managers for functional areas to varying degrees s A number of site managers also have regional

responsibilities, however, acknowledged that often double role is not that successful



s Overlap and ambiguity often exists for region and site roles s Matrix reporting extremely rare outside of pharmacy

department s Shared site management rare and usually only for very

small, geographically close sites s Manager span of control varied 1:20 – 1:30 s Site managers often had Senior Pharmacists/Coordinators

and Senior Technicians supporting them

II. Human Resource Management

s Recruitment and Performance Appraisals for Site Managers – Director of Pharmacy

s Recruitment and Performance Appraisals for Staff – Site Managers usually alone or in collaboration with Director or the Coordinators

s Single Bargaining Unit – usually one but may be different one for pharmacists and pharmacy technicians

III. Pharmacy Technicians Roles

s Increasing role of pharmacy technicians across the country s Tech check Tech varies from less than to equivalent to WRHA

IV. Region and Site Relationships

s Generally the Regional Director of Pharmacy has little to do with

site administration s Generally the Pharmacy Site managers are involved only in site

activities and committees that directly affect pharmacy or as designated by the Region as priorities

s Focus on regional initiatives and priorities s No apparent issues with site managers being pulled into site

committees/activities that Pharmacy Program did not consider important

V. Satisfaction with Model

s Generally satisfied with their model s Edmonton is considering dedicated regional functional

managers s Three of the regions expressed need to focus on improvements

in their clinical services



Appendix 5 Regional Pharmacy Program Career Ladder

PHARMACIST RECOGNITION PROGRAM – Draft #5

Table lists the qualifications required to attain the level identified

Clinical Staff Pharmacist

Activity Level 1 Level 2 Level 3 Level 4*

Level 5** (Clinical Leader)

Drug Distribution

- Pass probation at 6 months

- Meet basic drug dist. expectations

- All drug dist. 1 year expectations

Patient Care

- 1 year patient care expectations

- More mod/high complexity DRP’s

- More multi-disease states in pts

- Confident in use of 3°/2° DI resources to solve pt care problems

- Systematic review of pts

- Pt care team confident of recommendations made

- Incorporate extensive use of primary lit. in practice

- Expertise in specialty area

- Incorporate evidence based med and extensive use of primary lit.

- Expert national or regional

- Direct Patient Care and program related clinical services

- Therapeutic consultant?

Education - Orientates new staff

- Secondary preceptor for drug dist.

- Present case presentations

- Complete preceptor training

- Primary preceptor drug dist

- Progress from secondary to primary preceptor for clinical

- Nursing in-services

- Primary clinical preceptor (student, resident)

- Lecture at U. of M.

- Invited presentation

- Primary clinical preceptor (student, resident, grad student)

- MD in-services Leadership and Scholarly Activities

- Use scientific method to solve daily practice problems

- One volunteer prof. assoc. ??

- Site pharmacy committee???

- Pharm. site based committee

- Liaison with site pt care unit

- Poster presentation or article in local newsletter or other non-peer reviewed publications

- Dept/program related projects

- Committee outside of dept

- Committees (site/regional pharmacy, site/regional multidisciplinary, national representing pharmacy)

- Publications (peer reviewed)

- Approved projects (program/dept)

- Research (1°/2° investigator)

- Coordinate DUE - Prof. Assoc.

(active participant e.g. committee or leader)



*Level 4 Clinical Staff Pharmacist – Criteria for Advancement

To advance to a Level 4 CSP one must complete mandatory criteria and elective criteria: • Mandatory criteria

• Patient care • Incorporate extensive use of primary literature in practice. • Expertise in specialty area

• Education • Primary clinical preceptor (student, resident) (minimum 4

students, ? # residents) • Leadership and scholarly activities

• Dept./program related projects • Committee outside of dept.

• Elective criteria

• Must complete 2 activities in education and 1 activity in any 3 categories within leadership and scholarly activities listed below.

• Education

• Lecture at U. of M. to pharmacy undergraduates • Invited presentation (local or national) (minimum 2

presentations) • Primary clinical preceptor

• Pharmacy graduate student • Physician in-services

• Leadership and scholarly activities • Publication

• Non-peer reviewed (would include newsletter) • Poster • Peer reviewed

• Approved projects • Drug distribution related • Program related • Quality improvement • Research (1° or 2° investigator) • Coordinate DUE



• Committee • Site or regional pharmacy • Site or regional multidisciplinary • National (representing pharmacy)

• Professional association • Active participant

• Member of committee • Leader • Elected or appointed position

**Level 5 Clinical Staff Pharmacist – Criteria for Advancement

To advance to level 5 CSP, the following must be completed: • Patient care

• Incorporate evidence based medicine and extensive use of primary literature

• Expert (regional or national)

• Education • Lectures to undergraduate students • Mentor for undergraduate preceptor training

• Leadership and scholarly activities • Publication – 3 of 4 listed on previous pages – ? minimum # • Projects – 3 of 4 listed on previous pages – ? minimum #

Committee/professional association – minimum 2 activities



Appendix 6 ABC Staffing Adjustment Financial Plan

WRHA ABC Project

Revised Salary Reinvestments for Pharmacy

Program Pharmacy

Project Description 6.2 Regional Pharmacy Model

D a t a

Facility Labour Class

Sum of EFT (Savings)/

Reinvestment

Sum of BP

Estimates Sum of 2003/04

Sum of 2004/05

Sum of 2005/06

Sum of 2006/07

SBGH Pharmacists 5.4 527,467 128,400 399,067 0 0

Pharmacy Techs 5.4 198,575 48,551 150,023 0 0

SBGH Total 10.7 726,042 176,951 549,091 0 0

Various Pharmacists 17.3 1,700,712 414,000 1,286,712 0 0

Pharmacy Techs 17.3 640,264 156,544 483,720 0 0

Various Total 34.5 2,340,976 570,544 1,770,432 0 0

Grand Total 45.2 3,067,018 747,495 2,319,523 0 0

Documents

Regional Pharmacy Model