Pharmacy Practice Model Initiative: Case Studies in Health-System Pharmacy

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1 Advances in Pharmacology and Pharmacy 2(3): 54-58, 2014 DOI: /app Pharmacy Practice Model Initiative: Case Studies in Health-System Pharmacy Quyen Bach 1,*, Annesha Lovett 1, Teresa Pounds 2, Pamela Moye 1 1 College of Pharmacy, Mercer University, Atlanta, 30341, Georgia, United States 2 Pharmacy Clinical Services, Atlanta Medical Center, Atlanta, 30312, Georgia, United States *Corresponding Author: quyennbach@gmail.com Copyright 2014 Horizon Research Publishing All rights reserved. Abstract In 2008, the American Society of Health-System Pharmacists introduced the Pharmacy Practice Model Initiative (PPMI). The goal of this model is to promote pharmacy leaders, better manage resources, and increase focus on patient-centered and team-based care. Few studies have assessed the model s implementation. PubMed and CINAHL were searched using keywords pharmacy practice model, organizational, and the MeSH term, organizational, from 2008 to Of the forty-nine findings (articles and summit highlights), two case studies met the inclusion criteria. The first case study involved the University of Minnesota Medical Center, a multi-campus academic medical center. This facility used technology such as pagers for decentralized technicians, computerized provider order entry, and wireless computers on wheels. The implementation teams worked on clinical and distributive functions allowing for consistency in care and improved employee satisfaction. The second case study involved Providence Health & Services, a multihospital system in Washington State and Montana. These facilities used technology such as automated dispensing cabinets, order-image scanners, and automated telephone trees to route calls. The outcome was a positive economic impact with a return on investment of $709,321. An important finding was the lack of research assessing the implementation of the PPMI. Based on positive findings, it is evident that further research is warranted. Keywords Pharmacy Practice Model Initiative, PPMI, Models, Pharmacy Practice 1. Introduction In 2003, the American Society of Health-System Pharmacists (ASHP) launched an initiative with a goal that ASHP s vision for pharmacy practice in hospitals and health systems will be nationally recognized by the year ASHP s vision emphasized the pharmacist s role in promoting public health and ensuring the safety, effectiveness and evidence-based use of medications. According to the organizational website, many hospitals and other groups have embraced the 2015 initiative s goals and objectives to improve their practice and expand pharmacists recognition as contributors to national health care. 1 It is projected in the next five to ten years that financial pressure will force leaders in hospitals and health systems to reassess and implement changes regarding the use of pharmacy resources. 2 The economy, health care reform and advances in medication development are changing the nation rapidly, and the pharmacy profession must evolve accordingly. The medical team will acknowledge and expect pharmacists to assist in compliance with quality of care standards. These factors focus on a patient-centered, integrated pharmacy practice model that will improve the quality of care. Pharmacists in hospitals and health-systems are in the best position for this direction as many have shifted from filling orders and drug preparation to medication therapy management. Moreover, clear separation of duties present opportunities for more cost-effective use of pharmacy staff, greater consistency in service, and eradication of tension between the medical, nursing, and the pharmacy staff. Although previously published literature has shown that hospital-based clinical pharmacy has had a considerable positive impact on health care outcomes, an ASHP survey in 2009 showed only 65% of hospitals used an integrated pharmacy practice model, 24% used a drug-distribution-centered model, and 11% used a clinical-specialist centered model. Furthermore, up to 84% of survey participants expressed that the patient-centered pharmacy practice model was their preferred future pathway. 2 In 2008, ASHP and the ASHP Research and Education Foundation introduced the Pharmacy Practice Model Initiative (PPMI). At the 2010 Pharmacy Practice Model Summit, the goals of the PPMI were finalized by pharmacy leaders in health-system pharmacy practice showing recommendations on how to optimize the pharmacist s contribution to patient care and institutional sustainability [Figure 1]. The PPMI envisioned future hospital pharmacists to be more active in resolving complex medication therapy issues both in medication distribution and clinical pharmacy practice. 1

2 Advances in Pharmacology and Pharmacy 2(3): 54-58, Methods Figure 1. Pharmacy Practice Models Common Issues and Recommendations 3,4 Few studies have been done to assess the implementation of the PPMI across the United States which would serve as a valuable resource for hospital leaders who are interested in initiating the model at their facility. A literature review was conducted to search for studies which would provide a comprehensive description, of the implementation of the PPMI in the United States. A thorough search was conducted using PubMed and CINAHL with search terms pharmacy practice model, models, and organizational. 5 Case studies published on the PPMI website were also taken into consideration; however, they did not meet the criteria as a comprehensive outline of the implementation. 3. Results 3.1. PPMI Case Studies Although interviews, newsletters, summit highlights, and letters were retrieved from the literature, the following two case studies were the only findings that provided a comprehensive summary on implementation of the PPMI. Evidence suggests that case studies are among the best sources that provide an understanding of factual situations. 5 They are particularly helpful to explain steps in program implementation and evaluation. The first case study involved the University of Minnesota Medical Center (), a multi-campus academic medical center with 300 patients [Table 1]. 6 The University of Minnesota Medical Center was founded in the 1970s with a pharmacy service model composed of two divided work forces: clinical and distribution activities. Decentralized pharmacists were primarily responsible for entering medication orders from unit-based workstations while the clinical specialists were assigned to specialty areas. As a result, two groups of pharmacists with entirely different roles were present at the same patient care unit at the same time. The organization s vision for change was creating collaborating teams of decentralized pharmacists, decentralized pharmacy technicians, and team leaders to meet all pharmacy needs of the patient. Teams would work in alignment with department objectives regarding safety, quality, and cost savings. The facility used technology such as pagers for decentralized technicians, computerized provider order entry, and wireless computers on wheels for decentralized pharmacists [Table 2]. Key personnel included pharmacy technicians, clinical specialists, decentralized pharmacists, staff pharmacists, buyers, and managers. A new role was created for the technicians to round on the floors for drug distribution issues. The implementation teams worked together on clinical and distributive functions which allowed for consistency in patient care, expansion of pharmacy hours and services, and improved employee satisfaction [Table 4]. 6 The second case study involved Providence Health & Services (), a multihospital system with locations in Washington State and Montana. Providence Health & Services is comprised of various hospitals ranging from community hospitals with no pharmacy staffing outside of distribution to tertiary care teaching facilities with multiple decentralized clinical services [Table 1]. 7 The system s

3 56 Pharmacy Practice Model Initiative: Case Studies in Health-System Pharmacy administration desired to enhance the quality as well as the scope of pharmacy clinical services by implementing a patient-focused practice model throughout its network. The main goal was a systematic transformation from the traditional focus on order entry and distribution to focus on drug therapy management. These facilities used technology such as automated dispensing cabinets, order-image scanners, and automated telephone trees to route calls to technicians [Table 2]. The pharmacy director and hospital administrator introduced the initiative to staff. Training in therapeutic monitoring and documentation was an ongoing process. The outcome was a positive clinical and economic impact with a return on investment of $709,321[Table 4] Successful Implementation These two case studies provide useful insight and have highlighted significant benefits from the implementation of the PPMI. At, the value of the pharmacists was greatly increased because each was held accountable for all aspects of patient care. This allowed the pharmacist to have more knowledge regarding the patient s care; therefore, the quality of care improved due to less duplication of duties and improved communication. Positive feedback was received from nurses and other health care professionals as they only had to go to one pharmacist for all of their medication needs. Confusion and inconsistencies in medication services were eliminated. Productivity increased with the new practice model as evidenced by the lack of increase in full time equivalents (FTEs) with an increasing number of orders entered and verified. Since all pharmacists became responsible for clinical work, new staff was trained directly by an experienced clinician. Pharmacy residents reported that the integrated model ensured that they would be exposed to all levels of practice, resulting in a higher level of professional growth and confidence. The new model allowed the pharmacy staff to share accountability on clinical as well as operational tasks, creating a teamwork focused environment. Opportunities were present for all members of the department to advance their skills and practice. Both hospitals in the system reported a positive experience in the implementation of the PPMI. The number of interventions related to cost avoidance increased substantially every year from 2006 to The increase was particularly due to pharmacist authorization on dosing warfarin based on their developed relationships and clinical skill. Specifically, the associated cost avoidance increased, and the pharmacy supply expense decreased. Table 1. Case Studies Location/Design 6,7 Multiple campus academic medical center Multihospital system Located in Minnesota Located in Spokane, Washington Located in Missoula, Montana Census of 300 patients 200-bed community hospital a University of Minnesota Medical Center b Providence Health & Services c Providence Holy Family Hospital in Spokane, Washington d Saint Patrick Hospital in Missoula, Montana Table 2. Case Studies Resources 6,7 Pagers for decentralized technicians Computerized provider order entry (CPOE) Wireless computers on wheels for decentralized pharmacists Automated telephone tree to route distribution-related calls to a technician Order-image scanner technology Automated dispensing cabinets Table 3. Case Studies Interventions 6,7 Involved staff: pharmacy technicians, clinical specialists, decentralized pharmacists, staff pharmacists, buyers, and manager An outside facilitator was recruited to maintain objectivity, engage the group and guide the process Principles include: new role discussion, no job elimination, no salary reduction, salary-neutral and FTE-neutral, most advance practice performed by pharmacists, expanded clinical service hours, and cross-training to improve staff capability Pharmacy director and hospital administrator over pharmacy introduced the initiative to staff and expressed clear expectation Teams consisting of two primary pharmacists alternating monthly between staffing the clinical service and staffing centralized distributive positions Training was an ongoing process led by the pharmacy clinical manager, which include: therapeutic monitoring, documentation, disease management, specific protocols development (warfarin dosing, pharmacokinetics, and pain management)

4 Advances in Pharmacology and Pharmacy 2(3): 54-58, Table 4. Case Studies Findings Implications 6,7 One pharmacist on duty who is responsible for all aspects of patient care (order entry, distribution, and clinical tasks) ensures the pharmacist to know the whole patient more efficient caring; less disruption in caring and communication; eliminate only one go-to pharmacist for medication needs; pharmacy services are expanded, providing 24 hours a day, seven days a week; increased productivity Allowing a higher degree of alignment of the team with departmental goals Use of decentralized techs and automation to manage drug distribution allowed more pharmacist time to be focused on patient care Number of clinical interventions associated with cost avoidance documented by the pharmacist increased from 2005 (before implementation) to % (2006), 70% (2007), and 43% (2008) 134% from $11.00 (2005) to over $26.00 (2007) per patient day 33% (2006), 36% (2007), and 95% (2008) Associated cost avoidance increased 211% from $9.00 to over $28.00 per patient day Daily supply expense per case-patient day decreased $63.55 (2005) to $52.65 (2007) to $50.66 (2009) Decrease of $955,651 based on 2009 patient volumes Overall expense dropped from 50th percentile in 2005 to 25th percentile in 2009 when comparing with similar hospital (using Premier Outlook) Increase in staffing (not specified) $7.63 per case-mix-adjusted patient day from 2005 to 2009 Decrease of $593,781 based on 2009 patient volumes Return on investment No increase in staffing $709,321 in 2009 No specified 4. Discussions 4.1. Limitations to Implementation of the PPMI Although the case studies did not note any limitations, several may exist. Within the hospital setting, there may be a lack of the necessary authority to initiate the implementation of the PPMI and perform certain duties. Pharmacist staff, particularly senior pharmacists, may be reluctant to change or have difficulty adjusting to the new tasks. Moreover, they may feel like they are not knowledgeable enough to provide specific clinical services. Pharmacy technicians may not willingly take on new responsibilities or demand a raise, which may negatively affect the financial benefit. Furthermore, there may be a lack of human resources to train the technicians in fulfilling new responsibilities. 6 Pharmacists may raise concerns regarding liability for technicians errors refusing to delegate distributive activities. Additionally, implementation of the PPMI will require substantial use of technology to facilitate workflow. Issues with technology include the cost of new software systems, lack of understanding for optimal use, lack of user-friendliness, lack of informatics knowledge among existing staff, and lack of adequate number of staff to evaluate and implement new systems Lessons Learned There are several lessons to be learned from the implementation of the PPMI within these health systems. Sound procedures need to be in place to achieve successful implementation. The integration will occur more smoothly and successfully if the operations support both the distributive and clinical practices of pharmacists. It is imperative to anticipate issues that may result from the change. There may be staff members who perceive the change as a threat to their practice while others perceive it as an opportunity to improve care and enhance their careers. The leaders responsible for initiating the PPMI within a health setting should identify pharmacist perceptions and clearly discuss the goals and benefits that may result from implementation. 6,7 Furthermore, clear communication among key leaders within the organization is critical. identified three groups that played the most important roles in providing support. The first group was the hospital administration. Hospital administrators should be made aware of the benefits and goals of the new model and understand how the model will align with the overall institutional goals. The second group was the nursing team. Nursing leaders need to be able to recognize how the model would better support nursing practice. This can be achieved through meetings, in-services, and information sessions with required nurse participation. The third group was physicians. The key factors of the new model should be explained to physicians noting the positive effects, such as expanded clinical resources, improved continuity of care, and freedom from relying on only one individual on duty. Additionally, a complete yet concise list

5 58 Pharmacy Practice Model Initiative: Case Studies in Health-System Pharmacy of frequently asked questions (FAQs) addressing who, what, when, where and why questions should serve as a consistent message to all the staff in the pharmacy department. 6,7 Moreover, there is a need to carefully evaluate clinical skills along with leadership skills when seeking employees to fill new job positions. It is crucial for pharmacy leaders to act as role models with positive attitudes toward change. Leaders need to acknowledge that the changing of job duties will not affect the value of the staff member to the team. Expanding student programs including internships and residency programs is necessary. Involvement in student education is a vital component needed to raise the level of knowledge of the staff and aid in the recruitment of employees who are confident in performing a variety of duties. Finally, optimal use of technicians and automation as well as use of available space in the centralized pharmacy is perhaps one of the most valuable lessons provided by these case studies. 6,7 5. Conclusions In summary, this review demonstrated a lack of rigorous studies regarding the development and implementation of the Pharmacy Practice Model Initiative. Although various interviews, newsletters, summit highlights, and letters reflect the progress of pharmacists in the application of the model within health settings, future pharmacists will need to improve documentation by completing empirical research (e.g. observational studies). Of the 50 states in the United States, only three states were represented by hospitals that provided a full summary of the implementation of the PPMI. Published case studies of successful or even unsuccessful implementations will provide examples and valuable lessons that can be used by other organizations aiming to replicate the model in their own health care setting. Multiple case studies will provide different templates for implementation in different systems, such as those that are not an academic medical center or a multihospital system. This study also emphasizes the significance of documentation of the implementation. Since this implementation results in better patient care, it is similar to a patient intervention, which should always be documented. Documentation serves as a permanent record of proof of implementation and as a form of communication among health care practitioners in other health care systems. 9,10 The ASHP has called for the PPMI Hospital Self-Assessment, and the results to be published on the PPMI National Dashboard as a measure of progress in all states over time. 11 Successful stories of implementation have been posted under the Practice Spotlight section on the PPMI in the format of question and answer. 12 Nevertheless, a formal detailed step-by-step written paper would be of additional value. Documentation and publications are imperative since the PPMI could result in a positive impact on the pharmacy profession leading to increased pharmacist recognition for contributions to patient care and the ability to expand the role of the pharmacist. REFERENCES [1] Traynor, K. 215 Initiative yields to PPMI. Am J Health-Syst Pharm. 2012; 69: News. [2] Zellmer, WA. The future of health-system pharmacy: opportunities and challenges in practice model change. Ann Pharmacother. 2012; 46(suppl 1): S41-5. [3] Executive summary. Am J Health-Syst Pharm. 2011; 68: yresults.pdf (accessed 2013 Oct 10) [4] PPMI. Pharmacy Practice Model Initiative. Rationale. (accessed 2013, Oct 10) [5] Soy, Susan K.The Case study as a research Method. Unpublished paper, University of Texas at Austin. m (accessed 2014, July 2) [6] Knoer SJ, Pastor III JD, Phelps PK. Lessons learned from a pharmacy practice model change at an academic medical center. Am J Health-Syst Pharm. 2010; 67: [7] Pickette SG, Muncey L, Wham D. Implementation of a standard pharmacy clinical practice model in a multihospital system. Am J Health-Syst Pharm. 2010; 67: [8] Michigan Pharmacists Association Website. MSHP pharmacy practice model initiative (PPMI): Final results. yresults.pdf (accessed 2013 Nov 19). [9] Suter JW. Documentation basics: a guide to planning and managing documentation projects. New York State Archives.2003 [10] Ives TJ, Canaday BR, Yarborough PC. Documentation of pharmacist interventions. In: Schwinghammer TL, Koehler JM. Pharmacotherapy casebook: a patient-focus approach. 5th ed. -%20Instructor's%20Guide%20to%20Pharmacotherapy%20 Casebook%205e.pdf (accessed 2014 Dec 20). [11] PPMI. Pharmacy Practice Model Initiative. National dashboard. (access 2013 Aug 15) [12] PPMI. Pharmacy Practice Model Initiative. Practice spotlights. (accessed 2013 Aug 15)