Using pharmacists' perceptions in planning changes in pharmacy practice

Pharmacists' perceptions of and goals for clinical pharmacy services, as well as the proportion of time devoted to clinical services, were studied at one hospital as part of the process for establishing departmental goals. Three methods were used in evaluating pharmacists' perceptions of clinical pharmacy services. The first was a departmental survey. Second, staff members were asked to generate and prioritize a list of goals for clinical pharmacy services; this was done by means of an interactive, small-group process. Finally, a work-sampling study was performed that indirectly measured use of staff pharmacist and technician time. Staff pharmacists perceived that clinical pharmacy services were being provided to individual patients; however, support for these services from upper management was perceived as inadequate. Staff development had the highest priority for the further development of clinical pharmacy services. Only 19.7% of pharmacists' time was devoted to clinical services. Data from all three studies were incorporated into the development of a strategic plan that set forth long-term departmental goals and objectives. The plan includes a statement of commitment to develop management systems to eliminate deficiencies identified in the study. Among the changes in pharmacy operations introduced as a result of the survey were (1) a career-ladder system, (2) new opportunities for staff development, and (3) improved documentation systems. Surveying staff perceptions of existing services, joint goal setting and prioritization, and work-sampling studies formed the basis for the development and implementation of a new model of integrated pharmacy services at this institution.     

Role of the director of pharmacy: the first six months.

PURPOSE: Interviewing for a director of pharmacy position is discussed, and recommended activities for a pharmacy director's first six months on the job are described. SUMMARY: A prospective pharmacy director should first target the specific positions available that best fit his or her skills. The individual should tour the hospital and the pharmacy for each position of interest. Interviews should include the pharmacy staff, the nursing staff, the direct-report manager, and the medical staff. The hospital's financial condition should be assessed and a postinterview analysis conducted. Once hired, the new director should devote the first three months to an assessment of pharmacy services, staff, and customers; a regulatory and accreditation review; and assessments of organizational leadership, information systems, and clinical services. In addition, key documents, such as hospital policies and procedures, should be reviewed. At the end of the first three months, two documents, a summary of the new director's initial assessments and a chart showing current workflow, should be completed. Tasks for the first six months on the job include devising a work plan to address issues, developing reporting systems and metrics, setting priorities, creating staffing and clinical plans, promoting staff development creating and revising procedures, and evaluating outsourcing needs. The director should take a moment from time to time to celebrate successes with the staff. CONCLUSION: The director of pharmacy has one of the most complex jobs in the hospital. Planning, communicating, networking, writing, listening, leading, and motivating are skills necessary for success.     

Overestimating clinical functions of distributive staff pharmacists.

An unexpected outcome was obtained when an evaluation of the clinical functions performed by distributive staff pharmacists was completed. A random survey of clinical functions was completed by using a pharmacist activity log sheet. Direct observations made by pharmacy administration and information received through discussions with the staff pharmacists, over-estimated the actual amount of time being spent on clinical functions. Use of an integrated approach to pharmacy services requires that enough time for both distributive activities and clinical activities be appropriately balanced to assure effective intervention. PRN clinical pharmacy functions will produce sub-optimal results and negative long-term effects for the profession. Pharmacy administrators must prospectively monitor the clinical activities performed by members of their integrated staff and assure that adequate time is available for effective intervention in the drug use process. Subjective observations and information may not reflect the actual situation and should be considered extremely inaccurate.     

Strategic planning for clinical services: the University of Texas M.D. Anderson Hospital and Tumor Institute

A formal, hospitalwide strategic-planning process provides structure for the pharmacy's plans for implementing clinical services. The state-supported clinical cancer and research center began a formal strategic-planning process in 1981. The institution's planning report, prepared every two years and covering three two-year periods, drives the institution's budget through the state's biennial budget process. The report focuses on each department's responsibilities, areas of service, and relationship to the mission of the institution. Through the long-range planning process, upper-level administrators learned that pharmacy was eager not only to provide high-volume drug distribution services but also to assume direct patient-care and research responsibilities. This prompted an organizational change for pharmacy from a hospital department to a clinical division. The division of pharmacy now consists of three professional departments (patient care, pharmacy research, and pharmacy academic programs) and an administrative support service area. Services offered by each of the three departments are discussed, along with specific initiatives planned for the years 1987-1993. Within the next few years, all managers will come from the ranks of clinical practitioners; nonpharmacists will oversee financial and human resource functions. The division encourages existing pharmacy staff members to enhance their clinical skills through staff development programs. Strategic planning serves the dual purposes of structuring plans for implementing clinical pharmacy services and communicating pharmacy's goals within the institution.     

Strategic planning for clinical services: panel discussion

A panel of hospital pharmacy managers representing three institutions discussed issues related to planning for patient-oriented pharmacy services. The panelists discussed organizational benefits of strategic planning, ways to gain momentum for change among pharmacy staff members and from others within the institution, the need for setting realistic goals, and problems in differentiating roles for pharmacy staff. They also discussed the funding of strategic-planning programs. The panelists advocated an integrated approach to providing drug distribution and clinical services. Management must provide whatever support is necessary for integrating patient-oriented services into the daily activities of all pharmacists. That support may be in the form of additional personnel, better use of supportive personnel, staff development programs, or automation. Pharmacists, too, must recognize their combined responsibilities for drug distribution and clinical services. Only by having all pharmacists clinically trained can a department provide clinical services when needed. The experiences of these panelists may be useful to other institutions planning patient-oriented pharmacy services.     

Clinical services provided by staff pharmacists in a community hospital

A program for developing staff pharmacists' clinical skills and documenting pharmacists' clinical interventions in a large community teaching hospital is described. A coordinator hired in 1984 to develop clinical pharmacy services began a didactic and experiential program for baccalaureate-level staff pharmacists. Fourteen educational modules are supplemented by journal and textbook articles and small-group discussions of clinical cases, and the clinical coordinator provides individual training on the patient-care units for each pharmacist. Monitoring of clinical pharmacy services began in June 1987; each intervention provided by a pharmacist is recorded on a specially designed form. A target-drug program is used to document cost avoidance achieved through clinical services. Information collected through these monitoring activities is used to educate the pharmacy staff, shared with the pharmacy and therapeutics committee, and used to monitor prescribing patterns of individual physicians. The data are used in the hospital's productivity-monitoring system. All pharmacists who were on staff in 1984 have completed the educational modules, and all new employees are in the process. Since monitoring began, the number of clinical interventions has averaged 2098 per month. Cost avoidance has averaged $9306 per month. Over a five-year period, the development of staff pharmacists' clinical services raised the level of professional practice, produced substantial cost avoidance, and increased the number of pharmacist interventions in medication use.     

Strategic planning for clinical services: St. Joseph Hospital and Health Care Center

A pharmacy department at a 340-bed community hospital based its strategic plan for developing patient-oriented services on a sound drug distribution system, a credible work-measurement program, and fiscal responsibility. In 1982 the department of pharmacy and i.v. therapy implemented a strategic plan for improving pharmaceutical services. The plan involved developing goals and objectives for the department; marketing the department's services and fiscal management to hospital administrators, medical staff, and nursing staff; building teamwork among the pharmacy staff; and improving the drug distribution system before instituting clinical services. Hiring of additional pharmacy staff was justified on the basis of work-measurement data. By adjusting staffing levels every two weeks based on work-measurement data, the department increased the efficiency of drug distribution activities; the pharmacy also implemented cost-saving programs like selection of therapeutic alternates and formulary restrictions. The savings were then reinvested in labor-intensive patient-oriented pharmaceutical services. A staff development program using staff pharmacists as preceptors expanded the breadth and depth of pharmacists' clinical skills. The planning efforts were successful because the needs of hospital administrators, the pharmacy department, and staff members were addressed.     

Impact of computerization on clinical pharmacy services in South Atlantic states

The impact of computerization on clinical pharmacy services in the South Atlantic region was surveyed. Questionnaires were mailed to 350 hospital pharmacy directors in March 1987. The survey assessed type of computer system, degree of computerization, years computerized, hospital bed capacity, occupancy rate, staffing, presence of a clinical coordinator, and type of clinical services. For analysis of the relationship between clinical services and computerization, only responses indicating an increase in the number of clinical services since 1982 were used. Respondents were asked to rank, in order of importance, factors that they believed enabled clinical services to be increased. The survey response rate was 52.2%, with 179 of 343 usable replies received. The results indicate that there is a link between computerization and clinical services. Computerized pharmacies offered more services on average than did noncomputerized pharmacies. However, the differences in the types of services offered between computerized and noncomputerized pharmacies were not significant. Of the different means of increasing services, pharmacy directors ranked increasing professional staff the most important, followed by increased responsibility of technical staff, computerization, increasing technical staff, hiring a clinical coordinator, and other methods. Pharmacy directors interested in increasing the numbers of clinical services offered at their institutions should consider organizational factors such as departmental structure and number and types of personnel in conjunction with computerization.     

Survey of Canadian oncology pharmacy services--the emergence of a specialty

The provision of pharmacy services to oncology is a substantial component of hospital pharmacy practice at several Canadian hospitals. To determine the scope of such pharmacy services a survey was developed and distributed to 103 hospital pharmacies and 11 ambulatory oncology pharmacies in 1988. There were 72 responses (65%), although only 96 centres were known to offer oncology services (adjusted response = 72 of 96 = 75%). Surveys were distributed and returned in reasonable proportion across the country. Inpatient and outpatient services were reported separately, for size of service offered, and categories of work in which staff were employed. Twenty-four of fifty-seven centres report large inpatient pharmacist services, and 21 of 57 had large inpatient technician services. The ratio of pharmacists to technicians appeared to be about equal, but technicians were less likely than pharmacists to be permanently assigned (one-third vs. one-half permanently assigned). About one-half of both large and small services indicate a desire for increased time for both pharmacists and technicians. Outpatient services were reported by fewer respondents, and the job assignments in this setting were mostly permanent. Manpower usage in both settings is primarily dedicated to drug preparation and distribution, although two-thirds of centres report small clinical services (most centres desired increased clinical services). Future planning topics ranked improved clinical services and standardization of practice highest. A 91% majority agree that there should be standards for pharmacy practice in oncology pharmacists in Canada. Many factors, including insufficient clinical services, impede specialty development and recognition, but are priority areas for future development.     

Strategic planning for clinical services: Hamot Medical Center

As a result of a two-day strategic-planning program, a hospital pharmacy department developed a five-year plan for addressing seven critical issues facing the department. The pharmacy department at a large nonprofit community hospital began a formal planning process in 1981 after concluding that the existing clinical services had been implemented in a haphazard fashion and had mixed results. The planning process began with a two-day planning program aimed at identifying issues facing the department, followed by the development of consensus about the most important issues and the development of action plans for dealing with these. The planning program consisted of four parts: presentations by hospital administrators, nurses, and the medical staff on future directions in their respective areas and pharmacy's potential input; presentations on the future of pharmacy from the perspectives of the pharmacy director and the responsible hospital administrator; preliminary recommendations related to drug distribution services and clinical services by two pharmacy consultants; and discussions of departmental management issues and key points identified in previous sessions. The department's progress in addressing each of the seven critical issues is described; most of the action plan has been completed. The consensus-building planning process allowed the department to focus on the most important issues, identify support and possible conflicts from others, and obtain administrative approval of the department's focus on patient-oriented services.     

Hospital pharmacy staff development programs in Ohio

Although staff development programs have been used to implement clinical services in Ohio hospital pharmacies, the majority of clinical services have been implemented without the use of staff development programs. The results of this study show that less than half of Ohio hospital pharmacy departments provide staff development programs. In those hospitals where the programs were provided, the average number of clinical services implemented through staff development was not significantly different from the average number implemented without these programs. Nor was there a significant difference in the average number of clinical services implemented through staff development between small hospitals (199 beds or less), medium hospitals (200 to 399 beds), and larger hospitals (400 or more beds); between government (city, county, or state) and private, nonprofit hospitals; and between hospitals whose staff development program coordinators were directors and hospitals whose coordinators were not directors. For the majority of departments that provided staff development programs, certification or testing of pharmacists was not required before providing clinical services. Results from the survey indicated that certification may not be necessary for all clinical services. Commitment to staff development programs in terms of management support and participation, awarding of continuing-education credit, and use in pharmacist performance evaluations was demonstrated by no more than 34 percent of all departments that responded. Financial commitment to these programs was low. Overall, since less than half of the departments reported providing staff development programs, the level of commitment to staff development appeared to be low.     

Adjustments of distributive and clinical pharmacy services to financial constraints

The effects of hospital budget constraints on a pharmacy department's ability to provide distributive and clinical services are described, and the development and use of workload-monitoring systems to match resources with demand is discussed. In 1980, the pharmacy department at Grace Hospital, a 402-bed community hospital in Detroit, Michigan, began quantifying workload by using five drug distribution indicators. After the pharmacy began providing clinical services in 1981, workload elements were measured in a pilot program for ASHP's Hospital Pharmacy Management Information System. Hospitalwide staff reductions occurred in 1985, eliminating most clinical pharmacy services. From 1985 to 1986, drug costs increased more than expected; also, turnaround time for medication orders increased. In 1986, 1.4 full-time-equivalent positions were added, and the pharmacy instituted use of decentralized carts and a pharmacist on the patient-care units to provide first doses. The hospital's management engineering department had selected patient days as the single indicator for pharmacy workload, but pharmacy used the ASHP Pharma Trend monitoring system to present data that convinced management engineering that patient days was an inadequate indicator of pharmacy workload. Also, drug costs decreased after the drug distribution changes and the reinstitution of patient drug therapy monitoring. Pharmacy managers need workload monitoring systems that are responsive to changes and include departmental expense information; these systems should be able to interrelate to hospital cost-accounting systems.     

Expanding staff pharmacists' responsibilities to maintain pharmacy services in a neonatal intensive-care unit

The conversion of pharmacist responsibilities in a neonatal intensive-care unit (NICU) pharmacy satellite from drug distribution to both clinical services and drug distribution is described. When the pharmacy department could not recruit a specialty-trained clinical practitioner to fill an open NICU position, the position was converted to a fourth satellite pharmacist position, and each of the four NICU satellite pharmacists assumed clinical responsibilities for the NICU. Clinical and distributive functions had previously been separate. Staff development programs and a contract with the previous NICU clinical practitioner for consultative services helped to ease the transition. NICU pharmacists currently provide inservice education to medical residents and the nursing staff, provide drug information, monitor drug therapy, perform pharmacokinetic monitoring, are involved in research, and work to streamline satellite operations. For one of every four months, the NICU pharmacists primarily provide clinical services; the remainder of the time clinical activities are combined with drug distribution responsibilities. The staffing schedule has enabled the department to extend the hours that clinical services are available. The NICU pharmacists maintain secondary areas of staffing, and other pharmacists periodically staff the NICU satellite. Staff pharmacists in the NICU pharmacy satellite developed clinical skills that permitted integration of clinical and distributive pharmacy services.     

The management and development of hospital pharmacy in the new National Health Service in the UK

The introduction of an internal market in health care in the United Kingdom has created a structured relationship, defined by contracts, between health care providers, such as NHS hospitals, and purchasers, such as general practitioner fundholders. Similar relationships are developing within hospitals between clinical directorates and support service departments, such as pharmacy. A 1993/4 interview survey, conducted at eight hospitals, obtained the views of 129 pharmacy, nursing, medical and managerial staff on pharmacy service development and management in this new environment. Contracts between pharmacy and clinical directorates were in place in only two of the hospitals. Where contracts existed, pharmacy managers viewed them positively but they acknowledged the resultant managerial challenges. Most pharmacy managers at sites without contracts were threatened by the prospect of them. In contrast, non-pharmacy staff welcomed contracts as an opportunity to define their service requirements. For most managers of support services such as pharmacy, the implementation of the internal market will present challenges. Managers will need to become familiar with their customers' needs using information from several sources, including pharmacists working within directorates. Then efforts will have to be made to negotiate contracts that meet those needs while permitting the further development of staff and services.     

Documentation of the first steps of pediatric pharmaceutical care in a county hospital

Pediatric pharmaceutical care is still a new concept in the pharmacy profession. In our county institution with 35% of the beds reserved for pediatric patients, there existed no formal process for providing specialized pediatric pharmacy services. In an effort to rectify this situation, a study was conducted to determine the benefits of providing pharmaceutical services by having a clinical pharmacist round with physicians on a daily basis for 3 hours. All services provided were documented for 6 months and direct cost-savings were calculated. Five hundred four different interventions and services were provided, with over $7000 in savings. Because of these findings, the pharmacy and hospital administration agreed to provide a staff pharmacist to round in pediatrics on a regular basis. This approach is considered to be more cost effective than using a clinical pharmacist for daily rounds.     

PDCA循环管理法在医院药事与药物使用管理工作中的应用

目的介绍PDCA循环管理法在医院药事与药物使用管理工作中的应用实践。方法运用PDCA循环管理法的＂过程管理＂,即通过质量管理计划的制订、实施、检查及处置,实现医院药事与药物使用管理的质量持续改进。结果 PDCA循环管理法能促进医院药学管理科学化、规范化、常态化,有效提高药学部门各环节管理的工作效率。结论医院药事和药物使用管理使用PDCA循环管理法能夯实学科发展,促使药学管理质量循环上升,逐步提高临床医务人员和患者对药学服务的满意度。     

The implementation of comprehensive critical care pharmacy services through the development of a 24-hour satellite pharmacy

This report details the evolution of pharmacy services within the critical care areas of a large general hospital. The program began with the assignment of a clinical pharmacist to the intensive care unit and now includes a staff of six pharmacists operating from a 24-hour satellite pharmacy dedicated to critical care services. In the process a system has been developed which allows all staff to function in an integrated distributive-clinical role, eliminating the distinction between pharmacists performing these two separate functions. The system provides for total unit dose and IV admixture services as well as in-depth clinical monitoring, drug information and research responsibilities. Early impressions validate the success of this approach and objective evaluation, including the auditing of clinical input, is underway.     

Hospital pharmacy service provision in Australia--1998.

The results of a 1998 national survey of pharmaceutical services in hospitals throughout Australia are reported. A self-administered questionnaire was sent to all directors of hospital pharmacy services and senior hospital pharmacy managers to determine the extent of clinical and nonclinical pharmacy services provided by hospitals in Australia. Respondents chose the services their departments provide from a list of 26 commonly provided services. The response rate was 58.5%. Respondents were fairly evenly divided between teaching and nonteaching hospitals, but most of the respondents were from public (versus nongovernment) hospitals. The five most commonly provided services were imprest (a wordstock of frequently used medications that are regularly restocked by the pharmacy department), informal drug education for hospital staff, review of medication charts, control of drug purchasing, and inpatient dispensing. Review of medication charts and provision of drug education for the hospital staff were the most widely provided clinical pharmacy services. The most common services available from hospital pharmacies throughout Australia were imprest, informal drug education for hospital staff, review of medication charts, control of drug purchasing for the hospital, and inpatient dispensing.     

基层医院开展临床药学服务的体会

目的总结基层医院开展临床药学服务的经验和特点。方法回顾性分析本院过去2年内开展临床药学服务具体的实施方案及实施效果。结果本院的临床药学服务得到广大医护工作者和患者的认可,合理、安全、经济性用药得到明显提高。结论基层医院开展临床药学服务应根据医院自身的实际情况,确定开展药学服务的切入点,稳步推进,就可以取得良好的临床药学服务效应。     

Pharmacist career ladder with clinical privilege categories

The development of a career ladder program for staff pharmacists at a Department of Veterans Affairs (VA) medical center is recounted. Center policy required the establishment of clinical privileges for all pharmacists with direct patient contact and specified three VA privilege categories with increasing degrees of autonomy. The pharmacy department supported the need for all pharmacists to incorporate clinical activities into their daily practice but faced several problems, including inadequate instruction, insufficient incentives, fragmentation of clinical services, and subjectivity of measures of competence. In response, a pharmacy credentialing committee created a career ladder with three levels based on the established system of clinical privileges. Level A integrated basic clinical pharmacy knowledge with dispensing activities. Level B increased the number of clinical skills required and allowed the pharmacist to act as a therapeutic consultant. Level C incorporated the skills necessary for specialty practice. Instructors were designated for each clinical service area, readings and sample problems were assigned, and staff development presentations were improved. Objective tests of skills were designed. Combining the three levels on the career ladder with the three categories of clinical privileges formed a matrix of nine options for advancement. Pharmacists applying for advancement must master all requisite skills and submit relevant documentation. Each level carries a pay increase of 2%. A total of 53% of the staff pharmacists have participated in the program, which has had a favorable impact on staff retention. By combining nationally established categories of clinical privileges with an institution-specific career ladder, a pharmacy department helped ensure the consistency of services and promote the development of clinical practitioners.