TY - JOUR
AU - Kappeler, Karl, H
AB - Abstract Purpose In a rapidly changing healthcare landscape, pharmacy leaders must be agile and innovative to ensure that patients receive the highest-quality care. Here we describe the benefits of using a structured approach to pediatric pharmacy practice advancement guided by strategic planning and quality improvement principles. Summary Although there are many profound differences between pediatric and adult pharmacy management practices, many similarities also exist. Small- and large-scale change is most commonly guided by quality improvement methodology at Nationwide Children’s Hospital. Using this framework, the pharmacy practice model at Nationwide Children’s Hospital was reenvisioned to facilitate best patient outcomes and advance the role of pharmacists in the care of pediatric patients. Through these efforts, the percentage of inpatient hospital services with a pharmacist embedded into the care team increased from 67% to 90%, the number of pharmacists providing direct inpatient care increased from 27 to 50, and the number of ambulatory clinical pharmacists more than tripled, from 3 to 10. Enhanced clinical pharmacy services were developed to provide consistent care on weekends and holidays while striving to reach zero patient harm. Involvement of pharmacists and pharmacy technicians, alignment with the health system’s mission, and internal development of pharmacists through focused training programs were vital to successful practice advancement. Conclusion Significant practice model advancement in a pediatric healthcare system is achieved by using the organization’s common language for change, involving frontline staff in creating the vision, and leadership steadfastly committing to realize the vision. clinical pharmacy, hospital, pediatric, pharmacy service KEY POINTS Pharmacy practice advancement initiatives should be guided by sound strategic planning and quality improvement methodology to allow for flexibility throughout the change process. Change takes time because people take time to change. Involve the entire team— leadership and frontline pharmacists—in all steps of the planning and implementation process. Expanding the role of the pharmacist in patient care can be achieved through both external talent identification and internal talent development. Change takes a toll on leaders. Courage and conviction are important when working to advance the role of the pharmacist. To care for the specific needs of the growing pediatric and select adult populations serviced by Nationwide Children’s Hospital, a strategic effort was needed to develop a sustainable, forward-thinking practice model that facilitated the achievement of the highest-quality medication outcomes for all patients in all settings. The structure and form of these pharmacy services had to be developed based on the needs of these patients rather than on legacy models of pharmacy care. Upon completing the Pharmacy Practice Model Initiative (PPMI) self-assessment, discussing best practices, and reviewing lessons learned by others who had undergone practice model change, the pharmacy leadership team agreed that the previous practice model did not facilitate optimal patient care.1 Growth of inpatient bed capacity, rounding services, and patient acuity within the healthcare system required creative strategies to meet the growing need for clinical pharmacy services. Additionally, pediatric patient care was increasingly being delivered in the ambulatory care setting, where relatively few pharmacists practiced. Pharmacists were sought to lead medication-related population health initiatives, and the need to improve transitions in care with pharmacy involvement was identified. Past practice model development efforts within the organization had largely taken an inpatient-focused approach using staff pharmacists and clinical pharmacy specialists. Though appropriate to meet the demand for growth in clinical pharmacy services when created, these positions had become functional silos, increasing the potential for gaps in communication and care delivery. Further, there were few opportunities for professional advancement within this model. With advances in postgraduate training opportunities, recruitment and retention of highly skilled staff required a more stimulating practice that delivered a high quality of care across the institution. These realities required a concerted strategic planning effort to optimize pediatric patient care and effectively deploy pharmacists as an integral part of collaborative patient care teams. Background In 2009, the American Society of Health-System Pharmacists (ASHP) and the ASHP Foundation collaborated to create the PPMI to guide the direction of health-system pharmacy into the future. The collaborative effort comprised the following 3 components: (1) the PPMI summit in the fall of 2010, (2) a campaign to promote change, and (3) ASHP Foundation grant–funded demonstration projects. The PPMI, now expanded to the Practice Advancement Initiative (PAI), commenced with a conference at which participants strategized regarding how the profession may better own the medication-use process. The proceedings of the summit were published, as was an assessment to be used by hospital and health-system pharmacies to gauge baseline performance and set goals toward future best practices.2 The Nationwide Children’s Hospital pharmacy leadership team, energized by the PAI effort and motivated by the desire to provide better care for our patients, completed the PPMI self-assessment in 2013. The results propelled the redesign of our practice model to meet the growing medication therapy demands of pediatric patients. Traditionally, healthcare systems have struggled to embody the characteristics of successful high-reliability organizations: leadership, safety culture, and robust quality improvement.3 This is also true of pediatric healthcare systems, which are incredibly complex and often lack the necessary standardization to begin the incremental change process toward becoming a high-reliability organization. These tenets serve as an ideal foundation for enhancing pharmacy services, improving medication safety, and advancing the role of the pharmacist within healthcare teams. Pharmacists are uniquely positioned to be leaders in the change process as experts in the medication-use system, including in pediatric facilities.4 Nationwide Children’s Hospital is a freestanding pediatric academic medical center with 673 licensed and leased beds, over 18,000 discharges per year, and more than 1.5 million patient visits from all 50 states and 45 countries. Among freestanding pediatric hospitals, it has been a leader in promoting healthcare improvement through transformational leadership, a safety-focused culture, and continuous process improvement. Through a commitment to safety from hospital leadership, a hospital-wide commitment to zero preventable harm, and a strong adverse drug event quality improvement collaborative, harmful adverse drug events were decreased by 76.5%.5 As a result of these efforts, many individuals within the pharmacy department had been trained on quality improvement methodology and the tools used to facilitate process improvement. As the journey of practice model change began, it was apparent that these same approaches would be pivotal in assessment, planning, implementation, and measurement of outcomes related to pharmacy practice model change. Process The director of pharmacy convened an initial meeting of pharmacy leadership to begin assessment and planning for practice model changes in August 2013. The pharmacy leadership team agreed that there must be an overarching goal for the future pharmacy practice and that it should align with the organization’s vision and corresponding strategic plan, “Journey to Best Outcomes.” The hospital’s growth, commitment to safety, and expansion of services throughout the region required innovative approaches to providing patient care. The leadership team agreed that the overarching goal for the effort would be to achieve “best medication outcomes” for all our patients, in line with the organizational vision. To keep all teams aligned with this vision, guiding principles were developed and shared at the beginning of every planning meeting (see sidebar). Guiding Principles for Practice Model Efforts at Nationwide Children’s Hospital Our current pharmacy practice model likely does not facilitate optimal patient care. Our new practice model must be consistent with and supportive of the organizational strategic plan. We must be wary of our past inpatient-centric approach to care. We must understand well the nature and needs of our patients to develop the optimal practice model. We must be open to change. It is inevitable and necessary. We must work as 1 team. This is essential to achieving the best medication outcomes. Once the vision was cast, a streamlined structure to organize practice advancement efforts was developed based on quality improvement methodology espoused by the Institute for Healthcare Improvement.6,7 A culture of high reliability and patient safety was firmly established within the organization, leading to dramatic decreases in preventable harm events over the previous 5 years.5 Any practice model changes could not compromise these commitments. Thus, corresponding process and balancing measures were developed to assess the success of this initiative and to ensure that a high level of patient and medication safety was maintained. Practice model development and implementation The leadership team recognized that creating an entirely new practice model would be a years-long process and that support from the entire department would be necessary for success. Three large brainstorming groups were formed composed of individuals from all areas of the pharmacy department. Each group conducted a strengths, weaknesses, opportunities, and threats (SWOT) analysis of current pharmacy services and proposed a direction for practice model advancement. The results of the SWOT analyses were aggregated and presented to the pharmacy leadership team. Using a qualitative approach, the pharmacy leadership team reviewed and identified common themes creating 6 strategic outcomes (Table 1). Table 1. Strategic Outcomes Strategic Outcome . Examples of Interventions Implemented . Provide medication reconciliation at admission and discharge Expanded medication reconciliation at admission using student pharmacists and pharmacy technicians in the emergency department Formalized pharmacist’s role in transitions of care Piloted student pharmacist–driven meds-to-beds program Provide integrated clinical pharmacy services to achieve best clinical outcomes across the continuum of care Redesigned pharmacist roles and expectations Selected and trained patient care pharmacists Launched specialty pharmacy services Expanded outpatient clinical pharmacy services Developed EHR enhancements (eg, acuity scoring and TDM tools) Provide safe, accurate, and timely dispensing Implemented BCMP Optimized turnaround times and integrated outpatient pharmacy with shared EHR Improved communication (eg, standardized handoffs, reduced interruptions) Transitioned PN order verification to clinical pharmacists Continued EHR enhancements with dose standardization, and an electronic pharmacist handoff tool Closed 1 satellite pharmacy and consolidated distributive services in another satellite pharmacy Provide a consistent level of care to all patients Created weekend on-site clinical services (14 hours of coverage) Started float clinical pharmacist position to cover PTO Optimize cost-effective care using pharmacoeconomic and formulary management strategies Obtained access to select payer insurance networks Enhanced transparency of drug costs in inpatient setting Initiated perpetual inventory tracking via EHR in outpatient pharmacies Increase the percentage of pharmacy staff involved in scholarly activities Formalized mentorship program Created professional development index tool to level-set expectations and create accountability Protected time for research activities Provided other necessary resources (workspace, research ethics training, statistical support) Strategic Outcome . Examples of Interventions Implemented . Provide medication reconciliation at admission and discharge Expanded medication reconciliation at admission using student pharmacists and pharmacy technicians in the emergency department Formalized pharmacist’s role in transitions of care Piloted student pharmacist–driven meds-to-beds program Provide integrated clinical pharmacy services to achieve best clinical outcomes across the continuum of care Redesigned pharmacist roles and expectations Selected and trained patient care pharmacists Launched specialty pharmacy services Expanded outpatient clinical pharmacy services Developed EHR enhancements (eg, acuity scoring and TDM tools) Provide safe, accurate, and timely dispensing Implemented BCMP Optimized turnaround times and integrated outpatient pharmacy with shared EHR Improved communication (eg, standardized handoffs, reduced interruptions) Transitioned PN order verification to clinical pharmacists Continued EHR enhancements with dose standardization, and an electronic pharmacist handoff tool Closed 1 satellite pharmacy and consolidated distributive services in another satellite pharmacy Provide a consistent level of care to all patients Created weekend on-site clinical services (14 hours of coverage) Started float clinical pharmacist position to cover PTO Optimize cost-effective care using pharmacoeconomic and formulary management strategies Obtained access to select payer insurance networks Enhanced transparency of drug costs in inpatient setting Initiated perpetual inventory tracking via EHR in outpatient pharmacies Increase the percentage of pharmacy staff involved in scholarly activities Formalized mentorship program Created professional development index tool to level-set expectations and create accountability Protected time for research activities Provided other necessary resources (workspace, research ethics training, statistical support) Abbreviations: BCMP, barcode scanning during medication preparation; EHR, electronic health record; PN, parenteral nutrition; PTO, paid time off; TDM, therapeutic drug monitoring. Open in new tab Table 1. Strategic Outcomes Strategic Outcome . Examples of Interventions Implemented . Provide medication reconciliation at admission and discharge Expanded medication reconciliation at admission using student pharmacists and pharmacy technicians in the emergency department Formalized pharmacist’s role in transitions of care Piloted student pharmacist–driven meds-to-beds program Provide integrated clinical pharmacy services to achieve best clinical outcomes across the continuum of care Redesigned pharmacist roles and expectations Selected and trained patient care pharmacists Launched specialty pharmacy services Expanded outpatient clinical pharmacy services Developed EHR enhancements (eg, acuity scoring and TDM tools) Provide safe, accurate, and timely dispensing Implemented BCMP Optimized turnaround times and integrated outpatient pharmacy with shared EHR Improved communication (eg, standardized handoffs, reduced interruptions) Transitioned PN order verification to clinical pharmacists Continued EHR enhancements with dose standardization, and an electronic pharmacist handoff tool Closed 1 satellite pharmacy and consolidated distributive services in another satellite pharmacy Provide a consistent level of care to all patients Created weekend on-site clinical services (14 hours of coverage) Started float clinical pharmacist position to cover PTO Optimize cost-effective care using pharmacoeconomic and formulary management strategies Obtained access to select payer insurance networks Enhanced transparency of drug costs in inpatient setting Initiated perpetual inventory tracking via EHR in outpatient pharmacies Increase the percentage of pharmacy staff involved in scholarly activities Formalized mentorship program Created professional development index tool to level-set expectations and create accountability Protected time for research activities Provided other necessary resources (workspace, research ethics training, statistical support) Strategic Outcome . Examples of Interventions Implemented . Provide medication reconciliation at admission and discharge Expanded medication reconciliation at admission using student pharmacists and pharmacy technicians in the emergency department Formalized pharmacist’s role in transitions of care Piloted student pharmacist–driven meds-to-beds program Provide integrated clinical pharmacy services to achieve best clinical outcomes across the continuum of care Redesigned pharmacist roles and expectations Selected and trained patient care pharmacists Launched specialty pharmacy services Expanded outpatient clinical pharmacy services Developed EHR enhancements (eg, acuity scoring and TDM tools) Provide safe, accurate, and timely dispensing Implemented BCMP Optimized turnaround times and integrated outpatient pharmacy with shared EHR Improved communication (eg, standardized handoffs, reduced interruptions) Transitioned PN order verification to clinical pharmacists Continued EHR enhancements with dose standardization, and an electronic pharmacist handoff tool Closed 1 satellite pharmacy and consolidated distributive services in another satellite pharmacy Provide a consistent level of care to all patients Created weekend on-site clinical services (14 hours of coverage) Started float clinical pharmacist position to cover PTO Optimize cost-effective care using pharmacoeconomic and formulary management strategies Obtained access to select payer insurance networks Enhanced transparency of drug costs in inpatient setting Initiated perpetual inventory tracking via EHR in outpatient pharmacies Increase the percentage of pharmacy staff involved in scholarly activities Formalized mentorship program Created professional development index tool to level-set expectations and create accountability Protected time for research activities Provided other necessary resources (workspace, research ethics training, statistical support) Abbreviations: BCMP, barcode scanning during medication preparation; EHR, electronic health record; PN, parenteral nutrition; PTO, paid time off; TDM, therapeutic drug monitoring. Open in new tab Next, 6 work groups comprising inpatient, ambulatory, and support services members, staff pharmacists, clinical pharmacy specialists, and members of the pharmacy leadership team were formed, each focusing on 1 strategic outcome. Each member was able to self-select their group based on their outcome of interest. The work groups were tasked with identifying core pharmacy functions and services needed to provide high-quality patient care in each outcome area. Data sets were provided to each work group (Table 2). Daily activities of clinical pharmacy specialists, clinical generalists, staff pharmacists, ambulatory clinical pharmacists, and pharmacy technicians were also reviewed. Using a quality improvement approach, each work group developed specific aims, key drivers, and potential interventions (Figure 1). Table 2. Data Sets Inpatient Deidentified demographic information Common admission diagnoses Patient volume by unit Patient admissions, transfers, and discharges Average length of stay Medication order volumes by pharmacy location and hour of day Ambulatory Pharmacy locations Hours of operation Outpatient prescription volume (by hour) Percentage of prescriptions written in various clinics Capture rate by the prescribing clinic Inpatient Deidentified demographic information Common admission diagnoses Patient volume by unit Patient admissions, transfers, and discharges Average length of stay Medication order volumes by pharmacy location and hour of day Ambulatory Pharmacy locations Hours of operation Outpatient prescription volume (by hour) Percentage of prescriptions written in various clinics Capture rate by the prescribing clinic Open in new tab Table 2. Data Sets Inpatient Deidentified demographic information Common admission diagnoses Patient volume by unit Patient admissions, transfers, and discharges Average length of stay Medication order volumes by pharmacy location and hour of day Ambulatory Pharmacy locations Hours of operation Outpatient prescription volume (by hour) Percentage of prescriptions written in various clinics Capture rate by the prescribing clinic Inpatient Deidentified demographic information Common admission diagnoses Patient volume by unit Patient admissions, transfers, and discharges Average length of stay Medication order volumes by pharmacy location and hour of day Ambulatory Pharmacy locations Hours of operation Outpatient prescription volume (by hour) Percentage of prescriptions written in various clinics Capture rate by the prescribing clinic Open in new tab Figure 1. Open in new tabDownload slide Key driver diagram: integrated clinical pharmacy services. Abbreviations: amb care, ambulatory care; ECMO, extracorporeal membrane oxygenation; EHR, electronic health record; Endo, endocrine; FEN, full enteral nutrition; LVADs, left ventricular assist devices; Med Rec, medication reconciliation; MTM, medication therapy management; PA, prior authorization; Peds, pediatrics; Pt, patient; Rheum, rheumatology; RPh, pharmacist; Rx, prescription; TDM, therapeutic drug monitoring; TPN, total parenteral nutrition. Figure 1. Open in new tabDownload slide Key driver diagram: integrated clinical pharmacy services. Abbreviations: amb care, ambulatory care; ECMO, extracorporeal membrane oxygenation; EHR, electronic health record; Endo, endocrine; FEN, full enteral nutrition; LVADs, left ventricular assist devices; Med Rec, medication reconciliation; MTM, medication therapy management; PA, prior authorization; Peds, pediatrics; Pt, patient; Rheum, rheumatology; RPh, pharmacist; Rx, prescription; TDM, therapeutic drug monitoring; TPN, total parenteral nutrition. The pharmacy leadership team convened in fall 2014 to craft the 2015-2020 strategic plan targeting the identified strategic outcomes. In order to accomplish our specific aims, pharmacist roles, compensation, and organizational structures needed to be revised. The new structure created 3 roles for pharmacists: staff pharmacist, patient care pharmacist (PCP), and advanced patient care pharmacist (APCP); these were created and defined in alignment with literature on patient-centered pharmacy practice models.8 Equal importance and value of each role was emphasized (Table 3). Additionally, all pharmacist roles were converted to exempt status. This change was made to promote a culture of professionalism and to give each pharmacist reasonable autonomy to provide direct patient care. Town hall meetings were held to discuss the vision for the new pharmacy practice model. Staff pharmacists were asked to consider interest in PCP roles as a development opportunity. The leadership team communicated important commitments at these town hall meetings, including that there would be no reductions in force, changes made would be budget neutral or justified via new business plans, and the leadership team would be invested in training and developing our own talent while also recruiting new talent. Table 3. New Pharmacist Roles Within the Practice Model Pharmacist Role . Pharmacy Services Focus . Examples of Pharmacist Activities . Staff pharmacist Operations Distribution expertise, order verification, medication checking Patient care pharmacist Core clinical functions All core operations functions plus medication reconciliation, profile review, order verification, therapeutic drug monitoring, patient education Advanced patient care pharmacist Advanced clinical functions All core clinical functions plus medication optimization, therapy selection, care plan development, TPN/FEN management, pain management, technology optimization (eg, ECMO, dialysis, LVADs), pharmacogenomics Pharmacist Role . Pharmacy Services Focus . Examples of Pharmacist Activities . Staff pharmacist Operations Distribution expertise, order verification, medication checking Patient care pharmacist Core clinical functions All core operations functions plus medication reconciliation, profile review, order verification, therapeutic drug monitoring, patient education Advanced patient care pharmacist Advanced clinical functions All core clinical functions plus medication optimization, therapy selection, care plan development, TPN/FEN management, pain management, technology optimization (eg, ECMO, dialysis, LVADs), pharmacogenomics Abbreviations: ECMO, extracorporeal membrane oxygenation; FEN, full enteral nutrition; LVAD, left ventricular assist device; TPN, total parenteral nutrition. Open in new tab Table 3. New Pharmacist Roles Within the Practice Model Pharmacist Role . Pharmacy Services Focus . Examples of Pharmacist Activities . Staff pharmacist Operations Distribution expertise, order verification, medication checking Patient care pharmacist Core clinical functions All core operations functions plus medication reconciliation, profile review, order verification, therapeutic drug monitoring, patient education Advanced patient care pharmacist Advanced clinical functions All core clinical functions plus medication optimization, therapy selection, care plan development, TPN/FEN management, pain management, technology optimization (eg, ECMO, dialysis, LVADs), pharmacogenomics Pharmacist Role . Pharmacy Services Focus . Examples of Pharmacist Activities . Staff pharmacist Operations Distribution expertise, order verification, medication checking Patient care pharmacist Core clinical functions All core operations functions plus medication reconciliation, profile review, order verification, therapeutic drug monitoring, patient education Advanced patient care pharmacist Advanced clinical functions All core clinical functions plus medication optimization, therapy selection, care plan development, TPN/FEN management, pain management, technology optimization (eg, ECMO, dialysis, LVADs), pharmacogenomics Abbreviations: ECMO, extracorporeal membrane oxygenation; FEN, full enteral nutrition; LVAD, left ventricular assist device; TPN, total parenteral nutrition. Open in new tab Strategic outcomes During this journey to advance the practice of pharmacy, many interventions have been successfully implemented. Two strategic outcomes are discussed below in detail. Providing integrated clinical pharmacy services to achieve best clinical outcomes across the continuum of care. The previous practice model relied on inpatient clinical pharmacy specialists and staff pharmacists for care provision with very little overlap of clinical and operational functions. Many clinical pharmacy specialists had primary services, such as critical care, along with secondary services, such as a general pediatrics service. Our team believed that patients deserved access to pharmacists regardless of the admitted service. This practice advancement required 2 mindset changes. First, it required optimized operational efficiency. Second, identification and development of staff pharmacists wishing to directly interact with and serve patients were crucial. A training and assessment structure for the PCP role was developed based on the Pharmacists’ Patient Care Process (PPCP) published by the Joint Commission of Pharmacy Practitioners and the ASHP postgraduate year 1 (PGY1) residency standards.9,10 This training established core clinical skills, such as medication reconciliation and therapeutic drug monitoring, and professional skills to prepare pharmacists for interdisciplinary collaboration and patient advocacy in the pediatric setting. In total, the training program took 8 to 12 weeks to complete. Conservatively, the organization invested at least $250,000 to train previous staff pharmacists for PCP roles. By standardizing training and developing existing staff, the percentage of services with a pharmacist directly interfacing with the medical team to provide clinical pharmacy services has increased from approximately 67% to 90%, and the number of pharmacists providing direct inpatient care increased from 27 to 50 from 2015 to 2018. Recognizing that most patient care is provided in the ambulatory setting, a concerted effort was made to enhance ambulatory pharmacy services. For certain specialty medications, the complicated insurance and specialty pharmacy system led to delays in initiating patient therapy sometimes in excess of 40 days. To improve patient care, specialty pharmacy services were developed as a new business plan and implemented. The goals of these services included increased patient access and adherence to medications, increased pediatric pharmacist presence in specialty clinics, and improved clinical and pharmacoeconomic outcomes for patients. Ambulatory clinical pharmacists more than tripled, from 3 to 10, deployed in targeted specialty clinics. In addition, a call center was created for pharmacy technicians and pharmacists to navigate the complex clinical and medication access needs of patients. Providing a consistent level of care to all patients. Previously, the department provided around-the-clock clinical on-call services through clinical pharmacy specialists and postgraduate year 2 (PGY2) residents, which were most often used during evenings, weekends, and holidays. With a doubling of hospital census (inpatient and observation patients) over the course of 5 years and increasing workload on clinical pharmacy specialists, the work group recognized that this exacerbated the discrepancy in the level of care provided to patients. To gather qualitative data about on-call services, individual interviews were conducted with each clinical pharmacist. Clinical pharmacy specialists routinely described weekend on-call activities requiring more than 8 hours per day. These pharmacists would report feeling fatigued and that it seemed like they were working 12 straight days when taking on-call responsibilities during the weekend. To provide a more consistent level of care, on-site clinical pharmacy services were established on weekends from 7 am to 11 pm using both PCPs and APCPs. By expanding the weekend clinical pharmacy teams to include 3 team members on weekends and holidays, the workload of APCPs was better managed, and overall pharmacist engagement increased. To improve clinical efficiency, the electronic health record was enhanced to automatically identify patients in need of therapeutic drug monitoring and to enhance communication. Through repurposing of a staff pharmacist full-time equivalent, an additional APCP position was created to provide coverage for colleagues due to weekend responsibilities. The department also increased capacity through budget-approved residency program expansion and set a goal to increase the number of pharmacy residents from 5 to 10 annually by 2020. The current program has 8 residents with growth primarily through the creation of a postgraduate year 1 (PGY1) pharmacy practice residency program and expansion of the PGY1 community pharmacy residency program. A timeline of key PAI efforts and accomplishments is outlined in Figure 2. Throughout practice advancement efforts, a balancing measure assessing adverse drug events was tracked, demonstrating that the overall preventable adverse drug event rate has been sustained at an extremely low, nation-leading rate. Other balancing measures showed that pharmacist turnover has not increased and that engagement scores (measured in 2018) are stronger than ever throughout the department. Figure 2. Open in new tabDownload slide Nationwide Children’s PAI timeline (2013-2018). Abbreviations: CF, cystic fibrosis; ED, emergency department; EHR, electronic health record; hem/onc, hematology/oncology; HSPA, health system pharmacy administration & leadership; ID, infectious diseases; PAI, practice advancement initiative; RPh, pharmacist. SWOT denotes strengths, weaknesses, opportunities, threats. Figure 2. Open in new tabDownload slide Nationwide Children’s PAI timeline (2013-2018). Abbreviations: CF, cystic fibrosis; ED, emergency department; EHR, electronic health record; hem/onc, hematology/oncology; HSPA, health system pharmacy administration & leadership; ID, infectious diseases; PAI, practice advancement initiative; RPh, pharmacist. SWOT denotes strengths, weaknesses, opportunities, threats. Discussion For a pharmacy department with an established practice model, global changes were difficult for staff to embrace initially and tested the leadership team to its core. This practice advancement initiative resulted in changes to pharmacists’ job responsibilities, compensation structures, work schedules, and titles at our institution. Discomfort and passive resistance underscored the importance of a long-term commitment to these changes. Leaders who embrace such expansive initiatives must prepare themselves for the requisite grit to implement change and also periodically assess whether or not the changes are having desired effects. Courage and commitment to the goals of improving quality of patient care and advancing the role of the pharmacist must be unwavering. Whether assumed or explicitly identified, elements of quality improvement are used in strategic planning and implementation to achieve goals. The use of process improvement tools and methodology provides a structured approach to planning that values the creative process. It also provides a framework through which change may be implemented using an iterative approach, allowing interventions to be studied and improved prior to large-scale implementation. The use of balancing measures such as the overall preventable adverse drug event rate identifies unexpected negative outcomes and should be part of all major practice advancement initiatives. Leaders must know that flexibility is requisite throughout the change process. For example, clinical and operations staff for neonatal pharmacy services initially reported to 1 manager. While attractive in concept, the manager was challenged to have necessary subject matter expertise and bandwidth to manage both disciplines. Responsibilities were restructured within the leadership team to better align workload and expertise. Structural decisions must be individualized to each institution and remain adaptive as practice models continue to evolve. Although there are stark clinical differences in pediatric and adult patient populations and thus differences in pharmacy operations, many similarities in overall management and leadership remain. While flexibility is important, so too are consistency and pharmacy leadership alignment. Approximately 9 months into our practice advancement initiative, the director of pharmacy was promoted in the organization, creating a cascade of internal promotions and placing leaders in new or expanded roles. Careful messaging to senior health-system leadership and engagement of many pharmacy leaders allowed progress to continue. Furthermore, the involvement of many staff in creating the vision for the next practice model mitigated some of the risk of stagnation or regression when pharmacy leadership changes occurred. A unique element of this practice advancement initiative was the commitment to identify and develop existing staff pharmacists into PCP roles. Many organizations devote significant resources to residency programs, often without developing existing personnel. The development of an 8- to 12-week training program based on PPCP and ASHP PGY1 residency standards demonstrated a commitment to staff pharmacists that their value was recognized and their involvement was integral to the success of the new practice model. The creation of the PCP role also allowed for the APCP role, specifically, weekend and on-call workload, to be decompressed. Evidence continues to emerge from recently published studies citing high levels of burnout among pharmacists and with inpatient clinical pharmacists in particular.11,12 Some former clinical pharmacy specialists in the department were staunchly opposed to on-site weekend clinical pharmacy services. Reasons given included loss of weekends at home with family and loss of continuity of care in the specialists’ primary service areas. This seemingly inherent conflict of wanting to be ever-present for the patient care team while also feeling exhausted requires management to identify solutions to mitigate continuity-of-care losses while preserving the engagement of the clinical pharmacists. Since creating the additional PCP roles, reallocating work, creating a float clinical pharmacist position, and expanding on-site weekend roles, the engagement of pharmacists has continued to improve. When evaluated as a work unit, pharmacists in our institution moved from tier 2 to tier 1, according to the 2018 Press Ganey Workforce and Engagement Survey. While many changes have been made on our journey to providing “best outcomes,” more changes lie ahead. With the PAI entering its 10th year, a 15-member PAI 2030 panel recently convened to discuss future areas of emphasis to provide outstanding patient care. At our health system, future directions include the creation of standard expectations for medication reconciliation and transitions of care conducted by pharmacists and pharmacist extenders. In order to continue to standardize processes and create efficiencies, conversion from paper profiles to an electronic profile review will be completed, which aligns with initial topics under discussion in the PAI 2030 panel.13 A professional development index has been created and will be implemented to assess APCP nonclinical performance expectations and goals. During 2020, the vision for remote (telehealth) ambulatory pharmacy services will be created, and the pharmacy department also has set a goal to credential and privilege pharmacists by 2022, which will allow pharmacists to provide additional services to patients and close current patient care gaps. Finally, it is essential to continue to assess how the role of pharmacy technicians, a PAI 2030 panel discussion topic, and student pharmacists can be expanded to create efficiencies for pharmacists, enabling more pharmacists to provide direct patient care activities on a daily basis. Conclusion The results of the ASHP PPMI self-assessment and the pharmacy leadership’s desire to facilitate optimal patient care led to the redesign of the entire pediatric pharmacy practice model. When embarking on such major changes, quality improvement methodology allows for collaborative thinking, consensus building, and the development of appropriate measures of success. While more investigation is needed to fully understand the benefits of quality improvement in the development of new pharmacy practice models, this approach allows for agility to changing dynamics which may impact practice. Health systems and pharmacy leadership teams who espouse this approach are well positioned to respond rapidly to both internal and external drivers to achieve the best patient medication outcomes. Ultimately, acceptance of large-scale changes takes years to realize and requires managerial and leadership courage and conviction to see changes through to completion. Future strategic initiatives at our institution will continue to align with discussion areas in the PAI 2030 panel, our organization’s strategic plan, and, ultimately, the best patient medication outcomes possible for pediatric patients. An audio interview that supplements the information in this article will be available at www.ajhpvoices.org. Disclosures The authors have declared no potential conflicts of interest. References 1. Knoer SJ , Pastor JD III , Phelps PK . Lessons learned from a pharmacy practice model change at an academic medical center . Am J Health-Syst Pharm. 2010 ; 67 ( 21 ): 1862 - 9 . 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ASHP accreditation standard for postgraduate year one (PGY1) residency programs . https://www.ashp.org/-/media/assets/professional-development/residencies/docs/pgy1-residency-accreditation-standard-2016.ashx?la=en&hash=9FF7C76962C10562D567F73184FAA45BA7E186CB. Accessed January 23, 2019. 11. Jones GM , Roe NA , Louden L , Tubbs CR . Factors associated with burnout among US hospital clinical pharmacy practitioners: results of a nationwide pilot survey . Hosp Pharm. 2017 ; 52 ( 11 ): 742 - 51 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Durham ME , Bush PW , Ball AM . Evidence of burnout in health-system pharmacists . Am J Health-Syst Pharm . 2018 ; 75 ( Suppl 4 ): e801 - 8 . Google Scholar Crossref Search ADS WorldCat 13. Traynor K . Practice Advancement Initiative looks to next decade . Am J Health-Syst Pharm . 2019 ; 76 ( 14 ): 1004 - 5 . Google Scholar Crossref Search ADS PubMed WorldCat © American Society of Health-System Pharmacists 2020. All rights reserved. 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TI - Realizing the vision for pediatric pharmacy practice advancement through strategic planning and implementation
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxz340
DA - 2020-03-05
UR - https://www.deepdyve.com/lp/oxford-university-press/realizing-the-vision-for-pediatric-pharmacy-practice-advancement-elps5k8MLj
SP - 466
VL - 77
IS - 6
DP - DeepDyve
ER -