Transcript Developing Clinical Pharmacy Programs and Effective Pharmacy

William A. Miller, Pharm.D., MSc, FASHP, FCCP
Professor Emeritus, University of Iowa
At the conclusion of this presentation you
will be able to
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Critically evaluate the effectiveness of your current
practice model
Construct a practice model that focuses on
optimizing patient care outcomes and safety
Use new strategies to expand clinical pharmacy
services
Consider changes in your leadership and
management skills to improve your effectiveness
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Ideally individuals in executive or director positions have both
excellent leadership and manager skills
Anyone can be a leader
Leaders set the direction for the organization and influences people
to follow that direction. Managers follow the direction for the
organization and implement programs, and achieve goals and
objectives set by leaders
Leaders do the right thing and managers do things right
Leaders set direction by developing a clear vision and mission, and
conducting planning that determines the goals needed to achieve
the vision and mission. They motivate or influence people by using
various methods: facilitation, coaching, mentoring, directing,
delegating, and rewarding
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The manager administers; the leader innovates.
The manager is a copy; the leader is an original.
The manager imitates; the leader originates.
The manager focuses on systems and structure; the leader
focuses on people.
The manager relies on control; the leader inspires trust,
The manager has a short-range view; the leader has a longrange perspective.
The manager focuses on the bottom line; the leader has an eye
on the horizon.
The manager accepts the status quo; the leader challenges it.
The manager is the classic good soldier; the leader is his or her
own person.
The manager does things right; the leader does the right thing.
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Clear vision
Develop an administrative team with unity of purpose and values
Surround themselves with other individuals who have
complimentary skills
Proactive versus reactive: Seek to expand circle of influence
(Avoid saying “if only”)
Good communications skills (Respected by able to disarm people
and put at ease for communications)
Build relationships with key leaders: administration, medical,
nursing, etc.
Value different perspectives: Good listeners
Develop a positive departmental structure: openness, value of
every staff member,
Cultivates the “I and we will attitude”
High performance expectations (model and expect of staff)
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Pharmacy leaders set the direction for the
department
Leaders do things right and managers do
the right thing
Mangers have a short term view and leaders
have a long term view
Pharmacy leaders have a clear vision
Pharmacy leaders build relationships with
other hospital leaders
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Mission of the department of pharmacy
Vision for the department of pharmacy
Values of the department of pharmacy
Goals of the department of pharmacy
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Objectives aimed at achieving goals
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Actions plans are detailed steps to achieve a specific
objective with dates and accountable person
Actions plans lead to implementation and achievement of
goals and objectives
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◦ Short term goals: annual (one to 2 years)
◦ Long term goals: 3 to 5 years
◦ Goals are broad: Establish decentralized pharmacy services
◦ Example: Establish decentralized pharmacy services for all critical
care services by 6/2011
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Perceived value of pharmacists as providers of patient
care (“Providers”)
Leadership
Health care and pharmacy practice models
Qualifications and credentialing of pharmacists as
patient care providers
Required standard of care: Best practices
Present information technology/automation
Funding of cognitive services
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Develop an organizational chart matched to vision
Develop administrative team with shared values
Hire competent staff for all positions
Engage staff in planning and decision making
Elevate qualifications for providers of clinical
services: Residency, board certification
Credential and privilege pharmacists: Scope of
practice as patient care providers.
Develop a pharmacy practice model matched to the
vision
Use automation and technology effectively
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Use pharmacy technicians to reduce pharmacist
involvement in distributive and other technical
duties
Development systems to improve medication-usesystems
Champion improvements for the medication-usesystem
Align clinical services with regulatory requirements
and quality organizations
Align clinical services with funding opportunities
Align clinical services with institutional plans
Align pharmacy practice model to medical practice
model
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What strategy are you planning or presently
implementation to increase the quality or
quantity of clinical pharmacy services
provided by your department?
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Assure optimal drug therapy outcomes
• Effective drug therapy
• Safe drug therapy
• Cost-effective drug therapy
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Assure pharmaceutical care is coordinated and
provided collaboratively with other
pharmaceutical care providers
Assure effective relationships with patients that
lead to patient involvement, understanding,
adherence
Assure efficient and patient focused delivery of
care
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Abundant number of publications
documenting the value of clinical services in
inpatient and outpatient settings
◦ Most pharmacists in published studies were full
time clinical pharmacists on interdisciplinary
teams (i.e., generalists or specialists) and not
pharmacy generalists in an integrated system
(i.e., performing distributive as well as clinical
functions)
◦ Need for research comparing integrated, hybrid
and coordinated practice models
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Is specialized medical care better than care provided by
generalists?
Is interdisciplinary team care better than care provided
by one discipline?
Should pharmacists all have the same KSA or have
different KSA?
Should pharmacy teams be multidisciplinary like
medical teams? (pharmacy generalists, clinical
specialists, compounding specialists, informatics
specialists, safety specialists)
Can clinical pharmacy specialists have the same job
description as clinical pharmacists?
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Variable: Comprehensive to minimal
Comprehensive more likely in medium to large
hospitals
Diffusion of ADC for drug dispensing
Diffusion of decentralized pharmacists but variable
quality and quantity of clinical services provided.
Adoption and diffusion of clinical pharmacy services
has been slow
Rogers EM. Diffusion of Innovations
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A
Shift the curve to the left
Move up the curve
Rogers EM. Diffusion of Innovations
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Core Clinical Pharmacy Services
• Medication profile review to identify and address drug
related problems
• Target drug monitoring
• Provision of drug information as requested
• Participation in medical codes
• Participation in patient care unit team meetings
• Participation in drug policy development
• Medication reconciliation as needed
• Patient discharge counseling as needed
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Advanced and Specialized Clinical Pharmacy Services
• Prospective or concurrent treatment planning through
consistent participation on formalized interdisciplinary
teams (rounds)
• Comprehensive medication therapy management through
P&T approved protocols for monitoring drug therapy and
changing drug therapy (hospital wide or
department/division specific) or collaborative practice
agreements
• Clinical specialists (usually PGY1 residency and PGY2 in
specialized practice areas: Critical Care, Oncology,
Transplantation, Cardiology, Infectious Diseases)
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Expansion of health care (Most agree about the
benefits of expanding health care coverage)
Reduction in health care costs: (All agree need to
reduce costs of health care)
A lot of the public want expanded health care benefits
but don’t want to pay for it.
No interest group wants to be negatively impacted
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Potential Opportunities
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Need to take advantage of these opportunities as
health reform moves forward
◦ Team based care (Medical Home Model, Accountable
Care Organizations)
– Continuity/transitions of care/prevention of hospital
readmissions/prevention
– Medication therapy management services and
medication reconciliation
– Expanded use of technology and automation to improve
safety and efficiency
– Implementation of new reimbursement models
– Testing of various models to deliver care (comparative
effectiveness research)
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Potential threats
• Inadequate funding of clinical services (fee for service or
portion of funding provided to support patient care or a new
reimbursement method)
• Impact of cost reductions on funding of clinical services
(delayed implementation, reduction in services)
• Use of other providers to provide pharmaceutical care
because of political and/or economic reasons
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Evidence of the value of teams is sufficient
Evidence of the value of clinical pharmacy
services is insufficient
The diffusion of clinical pharmacy services,
as an innovation, was quite rapid
Inadequate funding of clinical pharmacy
services as a part of health care reform is a
potential threat to pharmacy
The “Medical Home Model” may provide an
opportunity to expand clinical services in
ambulatory care settings
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Model
◦ Model is defined as “structural design of something”
◦ Organizational chart reflects the practice model or structure
being used for the delivery of pharmacy services
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System
◦ A group of interacting, interrelated, or interdependent
elements forming a whole
◦ A system for the delivery of pharmacy services reflects the
practice model used
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Ideal Practice Model
◦ Allows achievement of the desired pharmacy service
mission, goals and objectives while adhering to core values
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Integrated model
◦ One pharmacist job description
◦ All pharmacists provide distributive and clinical
services concurrently
◦ Pharmacists rotate to central and decentralized
practice areas
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Hybrid model
◦ Central and decentralized pharmacist roles under one job
description: Selected central pharmacists assigned to
decentralized role on a rotating basis
◦ Decentralized pharmacists may only focus on target
monitoring and other clinical services, have concurrent
distributive responsibilities and rotate to central area to
staff
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Coordinated model
◦ Multiple job descriptions with different roles and
responsibilities: Centralize pharmacist, decentralized or
clinical pharmacist, clinical specialist
◦ Pharmacists supportive of various roles, capable (not
proficient) to perform different roles, and care is
coordinated (team approach) to achieve common goals
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Beliefs of pharmacy leadership which are
based upon experiences, training, values
and opinions of thought leaders and
organizations
Number and quality of staff
Use of information technology and
automation
Nursing, physician and hospital
administration beliefs and support
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Consultant recommendations
Politics
Model development
◦ Evolve by adding clinical to distributive services
◦ Rarely redesign of existing model but tweek of
existing
◦ Usually driven by beliefs and subjective opinions
◦ Lack of evidence-based research on effectiveness
of practice models and metrics for staffing to make
practice model design decision making more
objective
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Similar goals for pharmacy services:
◦ Safe drug distribution and medication use system
◦ Quality clinical services
Difference in service emphasis
◦ Safe drug distribution system maybe emphasized
or viewed as being more important than influence
on the quality of pharmaceutical care
◦ Are dispensing errors more significant than
prescribing errors?
◦ As pharmacy clinicians with good leadership and
management skills are appointed pharmacy
directors will clinical services be emphasized?
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Different definitions of quality clinical services
◦ Target drug monitoring and cost reductions as
outcomes (Often see in integrated models)
◦ Pharmacists on interdisciplinary teams share
responsibility for drug therapy outcomes with
physicians and other providers (Often see with
coordinated models)
Different assessment of the level of clinical services
actually being provided by the department
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Director
Pharmacists
Central staffing
rotation
Decentralized staffing
rotation
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Director
Central Pharmacists
Select Central
Pharmacists:
Targeted Monitoring
and MTM
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Director
Assistant Director
Central Pharmacy
Central
Pharmacists
Decentralized
Pharmacists
Coordinator
Clinical Services
Clinical
Specialists
Assistant Director
Outpatient Services
Outpatient
Dispensing
Pharmacists
Clinical
Specialists
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Director
Assistant Director
Inpatient Services
Centralized
Services/Lead
Assistant Director
Outpatient Services
Decentralized
Services/Lead
Central Pharmacists
Centralized
Services/Lead
Clinical Pharmacists
Outpatient
Pharmacists
Clinical Specialists
Clinical Specialists
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CPO
Director Inpatient
Clinical Services
Surgery Coordinator
Critical Care
Coordinator
Director Inpatient
Operations
Medicine
Coordinator
Business Director
Pediatric
Coordinator
Informatics Director
Director of
Education and Staff
Development
Director Ambulatory
Services
Outpatient Pharmacy
Coordinator
Clinical Services
Coordinator
CHIEF
PHARMACY
OFFICER
Director
Transplantation
Services
Director
Medical and
Surgery
Services
Director
Oncology Services
Director
Pediatric Services
Director
Psychiatry Services
Director
Outpatient Services
Director
Central Inpatient
Pharmacy Services
Team Leaders for
Clinical Pharmacists
and Specialists
Team Leaders for
Clinical Pharmacists
and Specialists
Team Leaders for
Clinical Pharmacists
and Specialists
Team Leaders for
Clinical Pharmacists
and Specialists
Team Leaders for
Clinical Pharmacists
and Specialists
Further organization
Central Pharmacists
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Chief Pharmacy
Officer
Director of
Community
Hospital
Administrative
Director
Director of
Ambulatory
Pharmacy Services
Director of Central
Pharmacy Services
Director of
Inpatient Clinical
Services
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Advantages of Integrated Practice Models
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Disadvantages of Integrated Practice Models
◦ Recruitment of pharmacists to provide clinical services easier
because larger applicant pool
◦ Scheduling of pharmacists easier
◦ Staff morale maybe enhanced because all pharmacists have the
same responsibilities and status
◦ Greater percent of patients may receive core clinical services
◦ Minimal level of clinical services may result (e.g., new order
review, target monitoring, drug information)
◦ Patient populations needing advanced patient care services
maynot receive sufficient services
◦ Pharmacists may not become essential members of
interdisciplinary teams and as a result miss opportunities to
improve patient outcomes
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Advantages of Coordinated Practice Models
◦ Pharmacists on interdisciplinary teams provide
advanced/specialized clinical services as essential team
members
◦ Clinical services provided to interdisciplinary teams better
(specialized knowledge, skills and abilities; greater
awareness of pertinent patient safety issues for the specific
patient population, repetition/proficiency)
◦ Better use of pharmacist knowledge, skills and abilities
(PGY1 and PGY2 residency training) leading to improved
employee satisfaction
Disadvantages of Coordinated Practice Models
◦ Creates scheduling problems
◦ Replacement of pharmacists more difficult
◦ Silos may develop and impair effectiveness of internal
pharmacy team while enhancing interdisciplinary teams
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Core clinical services should be provided to all patients.
Specialized/advanced clinical services must be available to all
patients requiring these services
Clinical services should be consistently provided
The model for the overall delivery of pharmacy services must be
efficient, effective and coordinated (team approach).
The model must fit the system used by the hospital and/or
medical staff for delivering patient care.
Providers of all pharmacy services must be competent.
An appropriate mix of staff with needed KSA must be employed
The model must result in a safe medication use system.
The model must result in pharmacists being essential patient
care providers and members of formalized interdisciplinary
teams.
Pharmacy residents must be included in the model as
appropriate
The model must result in a positive department culture, and high
morale and retention rates.
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Briefly describe your current practice model
and then answer the following questions.
How have you assessed the effectiveness of
your current practice model?
How are you planning to change your practice
model to further optimize patient care
outcomes and safety?
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Containment (Subsystems): Practice models
used by physicians and nurses need to be
considered in deciding on pharmacy
practice model
◦ Teaching hospitals with formalized
interdisciplinary teams and house staff different
than community hospital model with private
physicians and no formalized teams
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Ripple Effect of Change:
◦ Changing the type of pharmacists hired for
decentralized pharmacy positions affects
outcomes of the whole system
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Synergy: If all parts of the practice model are
working well and together, synergy is
achieved (optimum drug distribution, patient
care, drug policy and medication use
systems)
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Rule of the weakest link:
◦ Hiring a director who views pharmacy as a material
management versus a clinical department affects mission
and vision for patient care services to be provided by
pharmacists
◦ Placing unqualified pharmacists in clinical roles impacts
overall system (patient care outcomes diminished)
◦ Assigning a critical care pharmacist 50 patients or a
decentralized pharmacist 150 patients to provide
distributive and clinical services affects type and amount of
cognitive services provided
◦ Rotating pharmacists to different areas (central, patient
care) affects ability of pharmacists to become essential
members of interdisciplinary teams
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Different Perspectives on How to Design the
Best Pharmacy Practice Model to Optimize
Patient Outcomes
◦ Patient care effectiveness
◦ Patient care safety
◦ Efficiency of care (quality/costs)
Balance of outcomes
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Cognitive services to be provided
◦ Core clinical services
◦ Specialized/advanced clinical services
 Prospective involvement in establishing patient treatment
plans versus routine monitoring
 Collaborative drug and disease state management
◦ Core and specialized/advanced services will need to
change for pharmacy to continue to add value to health
care
 Specialized/advanced services today will become future core
services
 Specialized/advanced services in the future will be affected
by advances in health care, new drugs, pharmacogenomics,
advanced decision support systems
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Model Effect on Cognitive Services Provided
Cognitive Domain
Affective Domain
Evaluation
Characterization
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Synthesis
Organization
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Analysis
Valuing
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Application
Responding
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Comprehension
Receiving
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Knowledge
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Reviewing routine orders: Low to medium
Target drug monitoring: Low to medium
Managing anticoagulation: Low to medium
Developing best practice guidelines,
protocols: High
Determining best treatment plan for a
critical care patient with multiple disease
states: High
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Patient care acuity and complexity
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Size of the inpatient or ambulatory patient
population
◦ Quaternary and tertiary care versus secondary
care
◦ Type of patient care unit: Intensive care and
emergency department, step down or
intermediate care, general patient care
◦ Size affects overall staff resources needed to
provide comprehensive pharmacy services:
inadequate staffing compromises level of clinical
services.
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Number of patients per clinical pharmacist
or specialist
◦ Currently see150 to 30 for regular patient care
units, ICUs: 60 to 10
◦ The higher the patient number the less involved
pharmacists are in the care of individual patients
◦ Lack of pharmacy metrics
◦ Miller Numbers for Optimal Clinical Services: ICUs
20 maximum, patient care units, 40 maximum
◦ Numbers affect the ability to use an integrated
service practice model for all clinical pharmacists
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Use of pharmacy technicians for order fulfillment
◦ Medication histories and reconciliation
◦ Tech-tech programs
◦ Routine clinical monitoring
Use of automation and use of information
technologies available to increase efficiency and
safety of medication use systems
◦ CPOE
◦ Access to information: PC, Tablets, Remote
◦ Pharmacy computer system: SOAP, monitoring data,
evidenced-based recommendations
◦ Use of ADC as unit dose carts
◦ Use of order scanning technologies
◦ Use of bar-coding and electronic-MARs
◦ Decision support
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Physician and nursing practice models
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Opinions of key leaders in the organization
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Opinions of professional organizations
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Organizational effectiveness research
◦ Interdisciplinary teams in teaching hospitals versus private
practice model
◦ Hospitalist model
◦ Pharmacy, medical, nursing and administrative leaders
◦ Are clinical pharmacists essential to patient care teams,
desirable, or primarily valued as a drug information
resource or for teaching medical residents?
◦ Physician organizations: Critical care, ID, transplant,
oncology, pediatrics
◦ Pharmacy organizations: ASHP Best Practices, PPMI, and
ACCP statements
◦ Research on best practice models
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Are the involved pharmacists capable of
performing the new role?
Will the proposed change be perceived as adding
value to the jobs of the involved pharmacists?
Will the perception by the involved pharmacists of
the probability of value satisfaction from the role
change be sufficient to gain their support?
The pharmacists involved must not perceive the
cost of the change in role as being significant.
Involved pharmacists perception of the risk of
making the change should be low.
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No one model is the best fit for all pharmacy
organizations
The number and quality of staff affects the
pharmacy practice model selected by pharmacy
directors
Increased use of information technology and
automation enhances patient safety and the
delivery of clinical pharmacy services
All pharmacists should have the same
qualifications and job descriptions
Chief Pharmacy Officers are more frequently
appointed in large hospitals or health care
systems
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Critically analyze the effectiveness and
efficiency of your current practice model
Design and implement a model that
◦ Optimizes the influence of pharmacy on patient
care outcomes: effectiveness, safety and
efficiency
◦ Is a good fit for your institution
◦ Is efficient, synergistic and coordinated
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◦ Results in pharmacists being essential members
of interdisciplinary teams
◦ Places the interests of pharmacy leaders or
individual pharmacists secondary to what is the
best model for your patients
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Develop metrics to evaluate the
effectiveness and efficiency of your practice
model and revise the model as needed
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8.
Bennis W. On Becoming a Leader. Reading, MA: Addison-Wesley Publishing
Company; 1989.
Bond CA: Interrelationships among mortality rates, drug costs, total cost of care, and
length of stay in United States Hospitals. Pharmacotherapy 2001;21 (2): 129-141.
Bond CA: Clinical pharmacy services, pharmacy staffing and the total cost of care in
United States hospitals. Pharmacotherapy 2000;20(6):609-21
Bond CA: Clinical pharmacy services, hospital pharmacy staffing, and medication
errors in United States hospitals. Pharmacotherapy 2002;22 (2): 134-147
Economic evaluations of clinical pharmacy services-1988-1995. Pharmacotherapy
1996; 16(6): 1188-1208
Kaboli PJ, Hoth AB, et al.: Clinical pharmacists and inpatient medical care: a
systematic review. Arch Intern Med 2006; May 8;166 (9): 955-64.
Bond CA, Raehl CL: Clinical pharmacy services, pharmacy staffing, and adverse drug
reactions in United States Hospitals. Pharmacotherapy 2006 (6): 735-47.
Chisholm-Burns MA: US Pharmacists' Effect as Team Members on Patient Care:
Systematic Review and Meta-Analyses. Medical Care: 2010; 48 (10):923-933
58
9.
10.
11.
12.
13.
14.
15.
16.
17.
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy
practice and settings: Monitoring and patient education-2009. 2010; 67 (7): 542558.
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy
practice and settings: Dispensing and administration-2008. 2009; 66 (10): 926-946.
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy
practice in hospital settings: prescribing and transcribing-2007. 2008; 65 (9): 827843.
ASHP: PPMI (ASHP website). Accessed March 19, 2011.
Zellmer WA. Pharmacy’s future: Transformation, diffusion, and imagination. Am J
Health-Syst Pharm. 2010; 67: 1199-1204.
Knoer S, et. A;.: Lessons learned from a pharmacy practice model change at an
academic medical center. Am J Health-Syst Pharm. 2010; 67: 1862-1869.
Abramowitz P: The evolution and metamorphosis of the pharmacy pratice model. Am
J Health-Syst Pharm. 2009; 64:1437-1446.
Breland B. Believing what we know: pharmacy provides value. Am J Health-Syst Pharm.
2007: 64:
Dwyer CE. Managing people. In: Roven S, Ginsberg L, eds. Managing hospitals. San
Francisco, CA: Jossey-Bass Publishers; 1991.
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