Continuous quality improvement regulations for community pharmacy practice in the United States

ObjectivesIn the United States, medication errors are considered to be the cause of 7000 deaths annually. Continuous quality improvement (CQI) is a management process that focuses on continually and systematically evaluating the organization’s work process. In community pharmacy, CQI leads to enhanced patient safety through a reduction in medication errors and quality-related events (QREs). There is limited information about the variations in CQI regulations required by State Boards of Pharmacy (SBPs) for community pharmacy across the country. The objective of this study is to comprehensively describe CQI regulations required by SBPs for community pharmacy practice in the United States.MethodsThis was a cross-sectional study. Information regarding SBPs community pharmacy CQI regulations was collected electronically by surveying a representative of each SBP. In addition, a review of State Pharmacy Laws published online complemented the survey data. The percentage of states with CQI regulations for community pharmacy was estimated.ResultsOf the 50 Boards, 16 require pharmacies to maintain CQI programs to monitor and prevent QREs in community pharmacy. The most common elements of CQI programs include the management of known, alleged, and suspected medication errors that reach the patient (73%) and regular reviews of the pharmacy’s aggregate data of medication errors or incidents (73%). The North Dakota SBP regulation is the most comprehensive, followed by that of Iowa, Maryland, Massachusetts, and Montana.ConclusionThere is wide variation among SBP CQI regulations for community pharmacy practice. Standardization of CQI programs across Boards, including a national database for reporting medication errors and QREs would enhance patient safety.     

Coaching strategies for the Flip the Pharmacy practice transformation initiative in Pennsylvania independent community pharmacies

BackgroundFlip the Pharmacy (FtP) is a nationwide initiative to scale practice transformation in community pharmacies. Participating pharmacies are coached through monthly practice transformation initiatives and document their patient-care activities through Pharmacist electronic Care (eCare) Plans.ObjectivesThe objective of this study was to identify peer coaching strategies to facilitate practice transformation in Pennsylvania community pharmacies.MethodsThis was a qualitative study using semistructured interviews with practice transformation coaches and pharmacy champions participating in Pennsylvania’s FtP program. The interview guide was informed by the Consolidated Framework for Implementation Research and elicited information using the intervention characteristics, inner setting, characteristics of individuals, and process domains. Interviews were conducted in person or via telephone over a 3-month period. An inductive qualitative thematic analysis was performed to identify coaching strategies.ResultsA total of 18 key informants were interviewed: 6 pharmacy champions and 12 practice transformation coaches. The following 5 coaching strategies emerged: (1) learn to use the pharmacy’s specific Pharmacist eCare Plan software, (2) build a trusting relationship with the pharmacy, (3) engage all pharmacy team members in practice transformation, (4) adapt communication strategies to the pharmacy’s preference, and (5) tailor goals to the pharmacy’s stage of practice transformation.ConclusionThis study elicited 5 peer coaching strategies to support community pharmacy practice transformation initiatives. These findings can be used to further practice transformation efforts in community pharmacies through FtP and other initiatives aimed at expansion of community pharmacy patient care services.     

Interruptions in community pharmacies: Frequency,sources, and mitigation strategies

BackgroundInterruptions constitute a key part of the communication strategy for healthcare providers, including community pharmacy personnel. Previous research in other healthcare environments has shown that interruptions are very common and may present as patient safety hazards. One 1999 study, conducted in community pharmacy settings, found that interruptions were prevalent and associated with dispensing errors. In the last 20 years, pharmacies have expanded patient services and implemented new technology. Yet, it is unknown how these changes have affected interruption sources and frequency.ObjectiveThe objective was to characterize the frequency and sources of pharmacist task interruptions that occur in community pharmacies.MethodsA cross-sectional qualitative study design was used to evaluate the frequency and sources of pharmacist task interruptions in Wisconsin community pharmacies. The participants included 9 pharmacists and 9 technicians working in 2 independently-owned, 2 mass merchandise, and 2 hospital/clinical-affiliated pharmacies.ResultsInterruption rates ranged from 3 to 7 per hour across the 6 pharmacies. Sources of interruptions included: patients, technicians, self-initiated interruptions, technology used in the pharmacy, and a second pharmacist.ConclusionsInterruptions are common in community pharmacies and the causes are multifactorial. Prudent management of interruptions in these work environments may involve improved technician training and better designs of pharmacy technology.     

Assessing health literacy practices in a community pharmacy environment: Experiences using the AHRQ Pharmacy Health Literacy Assessment Tool

BackgroundThe Agency for Healthcare Research and Quality (AHRQ) developed the tool, “Is Our Pharmacy Meeting Patients' Needs? Pharmacy Health Literacy Assessment Tool” to evaluate health literacy preparedness of pharmacy environments from patient, staff, and environmental perspectives. The tool was designed at a clinic-based, outpatient pharmacy of a large, urban, public hospital. Despite the ready availability of this tool and the encouragement of AHRQ to adapt it to other environments, there is no published literature on the dissemination and translation of this tool in the community pharmacy environment.ObjectivesThe five objectives of this study were to: (1) pilot the AHRQ tool “Is Our Pharmacy Meeting Patients' Needs? Pharmacy Health Literacy Assessment Tool” in a community pharmacy environment; (2) evaluate and adapt the tool; (3) describe the use of health literacy practices from patient, staff, and independent auditor perspectives using the revised tool; (4) evaluate the effect of a low-intensity educational health literacy awareness program; and (5) identify opportunities to improve health literacy-sensitive practices in the community pharmacy environment.MethodThe study employed a mixed method, posttest-only control group design using community pharmacies in the Tulsa, OK area. Participants included community pharmacists, staff, patients, and independent auditors. Select pharmacy staff members were invited to receive a health literacy training program delivered by a nationally-recognized health literacy expert to raise awareness of health literacy issues. Approximately eight months after the program, pharmacy staffs were surveyed using a written instrument, patients were interviewed by telephone, and the study investigators performed independent environmental audits in each of the selected pharmacies. Results from auditor evaluations, staff survey responses, and patient interviews were compared for similarities and differences to provide a multidimensional perspective about the use of health literacy-sensitive practices.ResultsAfter piloting and adapting the AHRQ tool for the community pharmacy environment, 60 patients completed telephone interviews, 31 staff members completed surveys, and four independent auditors completed environmental audits in six study pharmacies using the revised data collection instruments. The majority of patients and staff were in agreement that written materials were easy to read. However, the auditors did not report equally high agreement regarding the readability qualities of the written materials. While the majority of staff reported use of literacy-sensitive communication techniques with patients, only a minority of patients reported actual communication with the pharmacist and use of literacy-sensitive communication techniques. At trained pharmacies, a significantly larger proportion of patients reported that the pharmacist spent enough time answering their questions (100% vs. 87%, P = 0.038), but a smaller proportion reported the pharmacists reviewed important information from the written information provided (30% vs. 57%, P = 0.035). A significantly smaller proportion of pharmacy staff also reported using the repeat-back technique at the trained pharmacies (40% vs. 79%, P = 0.035).ConclusionThis project is the first to report piloting, revision, and implementation of the AHRQ Health Literacy Assessment Tool in a community pharmacy practice setting. In addition to adapting data collection instruments and implementation strategies, opportunities that target training to facilitate use of literacy-sensitive practices and active patient engagement with literacy-sensitive communication techniques were identified.     

Evaluation of community pharmacy service mix: evidence from the 2004 National Pharmacist Workforce Study.

OBJECTIVES: To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services. DESIGN: Cross-sectional study. SETTING: Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies). PARTICIPANTS: Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey. INTERVENTION: Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists. MAIN OUTCOME MEASURES: Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services). RESULTS: Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index. CONCLUSION: Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.     

连锁药店和单体药店药学服务现状对比分析初探

目的:调查济南市长清区连锁药店和单体药店药学服务开展现状并进行对比分析。方法:基于系统性、科学性、层次性和可操作性四个原则,选取济南市长清区四家单体药店和八家连锁药店,通过实地发放问卷,指导填写的方式对84位购药顾客进行问卷调查。结果:连锁药店和单体药店在药店提供的药学服务内容、药学服务形式、建立顾客用药档案和顾客选择药店依据四个方面存在差异,连锁药店药学服务在药店人员配备、药店优惠经营和药学服务仪器配备方面占优势,单体药店药学服务在药店社区化管理方面占优势。结论:济南市长清区连锁药店和单体药店药学服务仍需进一步提高,两种性质的药店应利用自身优势,相互借鉴,共同完善药学服务模式。     

Reflections on the role of the pharmacy regulatory authority in enhancing quality related event reporting in community pharmacies

BackgroundGiven the demanding nature of providing pharmacy services, coupled with the expanded scope of practice of the professions in jurisdictions around the world, greater commitment to continuous quality improvement through adoption of quality-related event (QRE) reporting is necessary to ensure patient safety. Pharmacy regulatory authorities (PRAs) are in a unique position to enhance QRE reporting and learning through the standardization of expected practice.ObjectiveThis study was aimed to gain a better understanding of the perceived roles of PRAs in enhancing QRE reporting and learning in community pharmacies, and identifying regulatory best practices to execute such roles.MethodsA purposive case sampling approach was used to identify PRA staff members from two groups (Deputy registrars and pharmacy inspectors) in 10 Canadian jurisdictions to participate in focus groups in the fall of 2011. Focus groups were used to explore perceptions of the role of PRAs in enhancing and promoting QRE reporting and learning, and perceived barriers to effective implementation in practice. Thematic analysis was used to analyze the qualitative data.ResultsTwo focus groups were conducted, one with seven Deputy registrars/Practice managers, and one with nine pharmacy inspectors. Five themes were identified, including (1) defining QRE reporting and compliance, (2) navigating role conflict, (3) educating for enhanced QRE reporting and learning, (4) promoting the positive/removing the fear of QREs, and (5) tailoring QRE reporting and learning consistency.ConclusionsOverall, participants perceived a strong role for PRAs in enhancing QRE reporting and learning and providing education for pharmacies to support their compliance with reporting standards. However, PRAs must navigate the conflict inherent in both educating and promoting a process for achieving a standard while simultaneously inspecting compliance to that standard. Ensuring pharmacies have autonomy in operationalizing standards may help to mitigate this conflict. Finally, greater education for PRAs themselves to better inspect compliance and in order to better communicate the benefits of QRE reporting and learning to pharmacies would be beneficial.     

Pharmacists experience of and perspectives about recruiting patients into a community pharmacy asthma service trial

BackgroundResearch trials testing the impact of community pharmacy services require adequate and appropriate recruitment of patients by participating pharmacists, however, this step presents an ongoing challenge.ObjectiveTo identify factors affecting recruitment of patients in community pharmacies participating in a multi-center trial of a pharmacy asthma service in Australia (Pharmacy Trial Program – Asthma and Rhinitis Control (PTP-ARC).MethodsThe PTP-ARC protocol required identification and recruitment of seven eligible asthma patients per pharmacy. Pharmacists responsible for sites that failed to recruit or retain any patients into the PTP-ARC trial participated in a semi-structured telephone interview about their experiences with these elements of the trial. The interviews were recorded, transcribed and coded using QSR International's NVivo 11 software. The analysis was conducted with reference to the COM-B framework (Capability, Opportunity, Motivation).ResultsPharmacists from 47 of 50 eligible pharmacies were interviewed. Seventeen factors were isolated and mapped to the COM-B framework. Psychological capability (recruitment hesitancy, research literacy and health literacy), physical capability (technological barriers, staffing issues and pharmacy busyness), physical opportunity (patient busyness, trial timing, study protocol, support and location), social opportunity (health literacy and supportive milieu), reflective motivation (incentive for participation, simplification) and automatic motivation (patient attitudes and pharmacist-felt experience) were factors affecting pharmacists' participation. Challenges identified included: issues with the software, unfamiliarity with research procedures generally (and specifically with the PTP-ARC protocols), the patients' lack of interest and pharmacists’ lack of time.ConclusionsTo the best of our knowledge, this is the first study to focus on issues affecting patient recruitment into a pharmacy health services (asthma) trial in real time. To propel evidence-based trials towards practice implementation, user-friendly software, pharmacists’ training on research and patient-engagement and adequate remuneration to address pharmacist time issues need to be key foci for health services design and implementation research.     

Point-of-care testing for infectious diseases: Opportunities,barriers, and considerations in community pharmacy

ObjectivesTo identify opportunities to perform point-of-care (POC) testing and/or screening for infectious diseases in community pharmacies, provide an overview of such tests and how they are used in current practice, discuss how the Clinical Laboratory Improvement Amendments of 1988 (CLIA) affect pharmacists performing POC testing, and identify and discuss barriers and provide recommendations for those wanting to establish POC testing for infectious diseases services in community pharmacies.Data sourcesPubMed and Google Scholar were searched from November 2012 through May 2013 and encompassed the years 2000 and beyond for the narrative review section of this article using the search terms rapid diagnostic tests, POC testing and infectious diseases, pharmacy services, CLIA waiver, and collaborative drug therapy management. All state boards of pharmacy in the United States were contacted and their regulatory and legislative websites accessed in 2012 and January 2013 to review relevant pharmacy practice laws.Data synthesisPOC testing for infectious diseases represents a significant opportunity to expand services in community pharmacies. Pharmacist education and training are addressing knowledge deficits in good laboratory practices and test performance and interpretation. Federal regulations do not define the qualifications for those who perform CLIA-waived tests, yet few pharmacists perform such services. Fewer than 20% of states address POC testing in their statutes and regulations governing pharmacy.ConclusionPOC testing for infectious diseases could benefit patients and society and represents an opportunity to expand pharmacy services in community pharmacies. Existing barriers to the implementation of such services in community pharmacies, including deficits in pharmacist training and education along with state regulatory and legislative variance and vagueness in statutes governing pharmacy, are not insurmountable.     

An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain

BackgroundWith revalidation in pharmacy in the United Kingdom fast approaching, appropriate systems of revalidation in community pharmacy are required. With little known about the potential use of appraisals for evaluating fitness to practice in pharmacy professionals (pharmacists and pharmacy technicians) in this sector, research was undertaken to explore their potential utility in a revalidation process.ObjectivesTo examine existing structures and processes in community pharmacy appraisals in Great Britain (ie, England, Scotland, and Wales) and consider the views of pharmacy stakeholders on if, and how, appraisals could contribute to revalidation of pharmacy professionals.MethodsSemi-structured telephone interviews were conducted with senior staff (eg, superintendents and professional development managers) from chain community pharmacies as well as pharmacy managers/owners from independent pharmacies. Senior staff from locum agencies and pharmacy technician stakeholders were also interviewed.ResultsAppraisals were in place for pharmacists in most chain pharmacies but not in independent pharmacies. Locum pharmacists were not appraised, either by the companies they worked for or by the locum agencies. Pharmacy managers/owners working in independent pharmacies were also not appraised. Pharmacy technicians were appraised in most chain pharmacies but only in some independent pharmacies. Where appraisals were in operation, they were carried out by line managers who may or may not be a pharmacist. Appraisals did not seem to cover areas relevant to fitness to practice but instead focused more on performance related to business targets. This was particularly true for those in more senior positions within the organization such as area managers and superintendent pharmacists.ConclusionsExisting systems of appraisal, on their own, do not seem to be suitable for revalidating a pharmacy professional. Considerable changes to the existing appraisal systems in community pharmacy and employer engagement may be necessary if they are to play a role in revalidation.     

Helping Unlock Better Care (HUB|C) using quality improvement science in community pharmacies – An implementation method

IntroductionCommunity pharmacists’ optimal scope of practice extends far beyond traditional dispensing or compounding, and health promotion or chronic disease management services based in the pharmacy can generate significant social and economic value. But, with many competing demands and performance expectations from patients, payers, and policymakers, many pharmacies face challenges when introducing, maintaining, optimizing, or integrating their service offerings. Quality Improvement (QI) science may provide a practical change management framework for pharmacy professionals to lead their teams in embracing optimal scope and in making pharmacy-based services more feasible and attractive for all parties.Project aimsTo build community pharmacies’ capacity for continuous QI (CQI) and to understand how the implementation of CQI is best achieved in this setting.MethodsCommunity pharmacies will undertake a process of change within one or more existing pharmacy services. Participatory action research principles will empower these sites to identify their own opportunities for improvement, generate change ideas, and trial and study those ideas in practice, using a QI system built on the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles. An external Quality Facilitator will consult and train an internal Change Champion and other pharmacy staff to use QI tools and strategy. Mixed methods will be used to explore changes in pharmacy service quality, and to understand the experience of the pharmacy professionals taking part in the QI process.Intended outcomesTo assess the capacity and willingness of community pharmacies to undertake self-directed QI initiatives, with the support of an external Quality Facilitator and an established QI approach. Understandings surrounding the transferability of this process, including further scale-up, and the production of additional change management tools are additional potential outcomes of this work.     

Examining the association between the “My Pharmacist” model and the service quality of community pharmacies

BackgroundIn Japan, patients can freely choose medical facilities. Many visit different medical facilities for different diseases, and for convenience, often utilize the pharmacies neighboring these facilities. Accordingly, a “My Pharmacy” model was recommended, in which patients select a single pharmacy using their own judgement to receive proper medication services. A “My Pharmacist” model, in which the pharmacist is constantly involved in the treatment of a patient, was also proposed. However, patients’ evaluations of pharmacist/pharmacy services under these models have not been investigated.ObjectiveTo examine how a patient's constant involvement with the same pharmacist and pharmacy is associated with their evaluation of the quality of pharmacy services.MethodsA cross-sectional survey using a self-administered questionnaire was conducted among patients who used pharmacies periodically. Patients evaluated the pharmacist/pharmacy services and were classified into 4 groups (“My Pharmacy/My Pharmacist,” “My Pharmacy/Multiple Pharmacists,” “Multiple Pharmacies/My Pharmacist,” and “Multiple Pharmacies/Multiple Pharmacists”) according to the form of their usage of pharmacies and pharmacists. An intergroup comparison was then performed and correlations within each group analyzed.ResultsData from 3,492 individuals using 147 pharmacies were analyzed. “My Pharmacy” users had significantly higher scores than did “Multiple Pharmacies” users on patient experience of proper medication services (e.g., identifying duplicate medication) (p < 0.001). “My Pharmacy/My Pharmacist” users scored higher than the other three groups on four evaluation factors, including “pharmacy/pharmacist's interpersonal services” (“sharing and utilizing patient information,” “enhanced health support function,” and “consideration towards patients”), “patient satisfaction with the pharmacy,” “placing more emphasis on quality of interaction with pharmacist than on waiting time,” and “attitude when visiting healthcare facilities” (all p < 0.001).ConclusionThe findings indicate that highly tailored, in-person services provided by “My Pharmacists” are associated with not only with the degree of patients’ overall satisfaction, but also their evaluation of “the quality of pharmacist services.”