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Pharmacy’s True North

Jun 15, 2016

Lisa M. Gersema, Pharm.D., MHA, BCPS, FASHP

Editor’s Note: The following inaugural address was given by new ASHP President Lisa M. Gersema, Pharm.D., M.H.A., BCPS, FASHP, at ASHP’s Summer Meetings in Baltimore, MD, June 14, 2016. Lisa is Director of the Pharmacy and Residency Program, United Hospital, St. Paul, MN.

GOOD MORNING, EVERYONE, and thank you. This is such a special day for me, and I’m so glad that you have chosen to share it with me.

No ASHP president-elect has achieved this position without help from others. Many names come to mind as I think of all the family, friends, and colleagues who have guided me on my professional journey.

So, I want to take a moment to say thank you to everyone who has inspired, mentored, challenged, influenced, or educated me during my professional and life journey.

Although I cannot mention everyone, there are a few people I’d like to name.

Three individuals became trusted mentors and colleagues during key junctures of my career: Mark Woods, during my first job at St. Luke’s Hospital in Kansas City; Bruce Scott, who hired me at United Hospital in St. Paul where I’ve spent the last 20 years; and Sara White, during my transition from Clinical Manager to Director. It goes without saying that all three continue to assist me as I now embark on my latest journey as ASHP President.

Thank you to my ASHP Board colleagues — both current and past — especially Lynnae Mahaney, Janet Mighty, Janet Silvester, and Diane Ginsberg. Of course, I wish to thank my fellow Minnesotans, Chris Jolowsky and Kathy Schultz. I’m grateful to Henri Manasse and Paul Abramowitz for their outstanding leadership of ASHP and wisdom about pharmacy.

To all of my Allina colleagues — you are an exceptional group of leaders. I would especially like to thank Kristi Gullickson for her many years of friendship and professional collaboration. I must thank the pharmacists, technicians and pharmacy residents at United who are my daily source of inspiration. I have a wonderful group of past and current managers who epitomize teamwork … thanks to Deb, JoAnne, Shane, Kat, Jay, and Brenda.

I would also like to thank Mandy Richards, my boss and VP of Patient Care at United Hospital. I appreciate her support of me as Director of Pharmacy and especially during my pursuit of ASHP activities.

I’d like to thank my friend Mary Fran Tracy, who has joined us here today. Mary Fran and I grew up in the same home town, went to high school and college together, and our families were friends. She has given me a great deal of insight on nursing practice and the value and importance of serving in professional organizations. And, one of the most important things of all: She usually dog-sits my beagle, Maddie, while I am away at ASHP events! (Except of course, on this trip!)

And, finally, I would like to say thank you to my parents, Clarence and Louise, my siblings, Dave, Faye, and Kathy, and their families.

Their unconditional love and support has given me such a solid foundation on which to grow. I’m so pleased that Kathy and my brother-in-law Jeff are with us today — it certainly makes the day more special. Although my parents are no longer with us, I know that this would be a very proud day for them. I suspect that somewhere, my dad is beaming from ear to ear, and my mom is whispering to him, “Can you believe this is our little farm girl from Iowa??”

To be able to stand before you today — a group of dedicated and inspiring individuals whom I’m so proud to call my friends and colleagues — is such an honor.

Being elected president of ASHP is a wonderful, yet humbling feeling. When I first became involved with ASHP in 1999, being part of the leadership wasn’t on my mind. Rather, I joined ASHP to meet other practitioners, to learn how I could be a better patient care provider, and to expand my professional horizons.

Seventeen years later, ASHP has become a cornerstone of my practice. The connections and friendships I’ve made, as well as the opportunities for learning and sharing that ASHP has afforded me, have made an incredible difference in my professional life.

Advancing Pharmacy

Since its founding 74 years ago, ASHP has contributed to practice advancement in more ways than many of us know. Consider ASHP’s work to advance clinical pharmacy through the establishment of the Pharm.D. degree and its support for residency training and specialty certification. ASHP has advocated for enhanced roles for pharmacy technicians, developed standards for compounding and for pharmacy practice, and pushed for safe and effective medication-use technologies.

Let’s stop to consider how different practice looks today than it did in 1942:

  • We’ve moved from multi-day dispensing in bulk bottles to barcoded unit-dose packages dispensed from automated cabinets.
  • We’ve moved from nurses admixing on patient care units to USP 797-compliant clean rooms.
  • We’ve moved from pharmacists hidden away in a basement to pharmacists accepted as valued members of the patient care team.
  • And now, we’re moving far beyond traditional inpatient care to expand our care of patients across the healthcare continuum.

But we can’t talk about the past without linking it to the future. What will guide us on our professional journey in the coming months and years? We should be very proud of what we have already accomplished. But we must keep asking ourselves, “What’s next?”

To achieve greatness, we must focus our energy and passion to get to the next level of practice. Yes, we will achieve provider status — it’s just over the proverbial hill. But we must be prepared for the journey that lies beyond that.

To achieve greatness, we must focus our energy and passion to get to the next level of practice.

We must accept full accountability for patient care outcomes due to medication-use decisions in every healthcare setting. We must be prepared to successfully collaborate with other healthcare team members. We must embrace a culture of excellence in practice. And we must seek out avenues to lead patient care in our organizations.

These goals are the True North of our collective journey as pharmacists.

Along the way, we must expect distractions — additional healthcare reforms, regulatory challenges, limited resources — but our professional compass must be trained on our True North. We must not veer off the path by going where others may point.

As I began to think about my remarks today, four critical attributes of pharmacy’s True North came to mind: accountability, collaboration, excellence, and leadership. All have been critical guideposts throughout my career.

Let me say it again: Accountability. Collaboration. Excellence. Leadership.

If we strive consistently to achieve them throughout our professional journeys, the prospects for pharmacists will be bright.

Accountability

The first construct of pharmacy’s True North — accountability — can be challenging to define. It is frequently interchanged with “responsibility” or “ownership.” Some may even associate it with liability.

Let me give you an example that helped shape my understanding of accountability for pharmacists.

Early in my career at St. Luke’s Hospital in Kansas City, our senior surgery resident shared his dislike of our aminoglycoside dosing service. (Yes, this was more than 25 years ago!) Now, I was very proud of this program. I considered it our launching pad for clinical services at the hospital, and I had worked very hard to teach our staff this skill.

You can imagine my dismay when the surgical resident said that he didn’t like the service. He went on to explain why he felt this way. Apparently, even though he thought the recommendation for a dose change was reasonable, he might challenge the pharmacist just to see how they would respond. He was amazed when they didn’t push back, but instead said, “OK,” and hung up the phone.

The resident then said to me, “If you believe in what you are doing, you have to fight for it.” Although I didn’t realize it at the time, this conversation was one of my first lessons in accountability. And it propelled me to teach our pharmacists how to respectfully fight for what they believe in.

It was true then, and it’s true now.

I doubt that the patient admitted early on a Saturday morning has fewer medication issues or challenges than another patient admitted on Wednesday at 10 a.m.

This conversation struck me again several years later during an ASHP Policy Week. I was chair of the Council on Pharmacy Practice and one of our agenda items was titled, “Pharmacist Accountability.” At first blush, this seemed like a daunting topic. The content of the scholarly articles that were provided as background reading was complex, and the discussion was insightful and energizing.

On that day, I had an epiphany. Unless we, as a pharmacy profession, accept full accountability for medication management and every related issue, our personal career aspirations and larger goals for the pharmacy profession will be difficult to achieve. After that discussion, no action or recommendation made sense to me unless it was prefaced by pharmacists accepting accountability for our actions.

On the face of it, the word accountability seems to have a simple definition: “The obligation of one party to provide a justification and be held responsible for its actions by another interested party.”

But when you start to break the definition into its components, it becomes more nuanced and complex:

  • “One party” refers to each of us as a pharmacist and collectively as a pharmacy department and profession.
  • “Another interested party” clearly refers to our patients. But it also represents our employers, other healthcare providers, the legal system, and society as a whole.
  • “Action” is two-pronged. We have to either do something or we have to consciously not take action.
  • “Provide a justification” means that we need to be able to support and defend our action or lack thereof.
  • “Held responsible” points to the fact that we must accept the consequences of our decisions and actions.
  • And “Obligation” refers to a sense of duty, a promise to act.

This definition is quite complex for a word that, on its face, seems simple.

You know, one thing that particularly strikes me about accountability is the requirement to look at our decisions through the lens of “another interested party.” This is a daunting prospect, isn’t it? We must constantly ask ourselves:

  • Are we doing the right thing?
  • Are we available enough?
  • Do we embrace a sense of duty to help our patients?

Over the years, I’ve questioned certain aspects of our traditional pharmacy staffing models. For instance, do your pharmacy staffing and services look different at 2 a.m. on a Saturday compared to 10 a.m. on a Wednesday? I bet they do. I know mine do.

And yet, I doubt that the patient admitted early on a Saturday morning has fewer medication issues or challenges than another patient admitted on Wednesday at 10 a.m. What is our accountability to our patients, no matter when they arrive in our healthcare settings and institutions?

ASHP has a unique perspective on pharmacist’s accountability. In 2010, the Council on Pharmacy Practice developed a policy statement on pharmacist accountability for patient outcomes. It had taken several years of discussion and feedback to develop a statement that captured all of the critical components.

I placed the statement into a word cloud, as you can see here. The size of each word reflects the number of times that it is stated in the document. It’s no surprise what stands out. These key words say all that needs to be said about the importance of accountability for pharmacists.

Accepting accountability can be challenging and even a bit frightening. But the rewards and recognition that come our way when we exhibit accountability to our patients, our healthcare partners, our profession, and our entire society are incredibly rewarding.

Collaboration

I imagine that some of you may be thinking, “We do take ownership of issues. Pharmacy owns the medication-use system. Isn’t that accountability?” The answer to that may be “yes,” but could the outcomes be even better?

Indeed, how pharmacy-centric are we? And what are we missing if we don’t seek out highly collaborative relationships?

Like accountability, the word “collaboration” is a complex behavior that is often misunderstood. Collaboration originates from Latin and means to “labor together.” To be collaborative means to value opinions and experiences of others that differ from our own.

I truly believe that a strong and effective medication management system cannot be orchestrated by pharmacy alone.

The good news is that pharmacists have never had more opportunities to collaborate… as members of interdisciplinary patient care teams, with pharmacy colleagues in different settings across the continuum of care, and among professional disciplines as we develop programs, policy, and care approaches together.

I truly believe that a strong and effective medication management system cannot be orchestrated by pharmacy alone. This system actually consists of a triad of pharmacists, nurses, and physicians. Each discipline is responsible for one side of the triangle — with the patient located safely in the middle.

Each discipline owns a unique set of knowledge and responsibilities that contributes to the safe and effective use of medications for our patients. When we focus to develop a shared pool of understanding, we create a trust and synergism that results in the best care for patients.

The key question is how do we, as pharmacists, interact with our partners in patient care? Are we occasionally dismissive of their requests? After all, we’re the medication experts, and we know best. Or do we back down in the face of a colleague’s challenge when we should step up?

I recall a situation that happened several years ago when I jumped to conclusions before understanding a situation. This involved an error when a nurse had administered vasopressin to run at 400 mL/hr to a critically ill patient. Yes, that’s right… 400 mL/hr.

When I heard this, I immediately questioned how any nurse — especially one in the ICU — would ever think that 400 mL/hr was an acceptable rate for any medication-containing infusion. I certainly had preconceptions about assigning blame.

Clearly, this was a serious error, but the list of issues that contributed to it was very revealing. To name just a few:

  1. The nurse was a new hire and had floated from a different ICU mid-way through his shift — and he was unfamiliar with vasopressin.
  2. Instead of paging the pharmacist, the nurse checked his own resources for information on vasopressin.
  3. The intensivist gave a verbal order to the pharmacist, but wrote the order differently — the nurse administered the order as written.
  4. The electronic charting system was not programmed to match how our intensivists typically ordered vasopressin.

This was a serious medication error simply waiting to happen. Yes, it was the classic example of Swiss cheese issues. But I also wondered how things might have been different if this nurse had felt comfortable enough to collaborate with the pharmacist.

What would have changed if the pharmacy department had effectively collaborated with the medical and nursing staff to establish safe processes for prescribing and administration of vasopressin? Better accountability and collaboration would have avoided a serious medication error.

Research demonstrates that team-based care and clear communication are the keys to medication safety and good patient outcomes. Indeed, the Joint Commission has suggested that over 60 percent of medication errors are the result of poor communication.

Other studies confirm this finding, including one that evaluated the outcomes of over 5,000 patients receiving care in 13 different tertiary care hospitals. The study discovered that the level of interprofessional interaction and coordination of care had greater impact on positive patient outcomes than the number of specialized services available at each hospital.

That’s astonishing, isn’t it?

When we join forces, we view the situation through many eyes, and we are able to gain new insights and better understanding of the big picture.

Clearly, everyone wins through collaboration. When we join forces, we view the situation through many eyes, and we are able to gain new insights and better understanding of the big picture. This partnering must occur at all levels — obviously during patient care, but also during policy and program development and strategic planning.

I imagine that many of you have experienced being part of a high-performing team. You can feel its synergy — the trust and positive energy. Your contributions are valued, and you respect the other team members. It’s an incredible feeling.

That doesn’t mean that this process is easy. We must always maintain the delicate balance between sharing our expertise and advocating for what we believe. We also must learn from members of the team with different expertise who may hold a different view of the same situation. That diversity helps us to move beyond a relatively narrow and pharmacy-centric view on the world.

As author Nancie O’Neill once said, “When different talents and ideas rub up against each other, there is friction, yes. But also sparks, fire, light, and eventually brilliance.”

Excellence

The third construct of pharmacy’s True North is excellence.

Now, more than ever, we must be able to effectively justify our actions to ourselves and to others. To do so, we must demonstrate an excellence in our practice and our medication knowledge that is second to none. Of course, with today’s advanced technology, we have a plethora of data at our fingertips. But without pharmacists’ professional insights and ability to apply this data to a specific patient or situation, it is just that — data.

One of the most important skills that pharmacists have learned in terms of patient care is our ability to defend the rationale behind personalized medication care plans. We must anticipate occasional push-back. We may even hear statements like, “I’ve never done it that way,” or “I haven’t seen that in my experience.”

But we must be confident and skilled enough to demonstrate our clinical excellence by effectively and efficiently sharing the rationale supporting our actions with the patient and other members of the healthcare team. We must be resolute. We must stand behind our recommendations.

On a broader scale, if we want to be seen as healthcare providers, we need to understand that other healthcare professionals, administrators, credentialing departments, third-party payers, and even our patients will look for evidence that a pharmacist is qualified to accept this important medication management responsibility.

That’s why I believe that advanced training with residency programs and completion of board certification is an essential external validation. Another aspect of being excellent practitioners is to recognize and value the importance of lifelong learning and skill set development. Consider this: On average, human knowledge is doubling every 12 months. And the scientific route from a pioneering discovery to a new drug — which once took decades — now takes years, and in some cases, only months.

Let me illustrate what this pace of change has been like for me personally. During pharmacy school, my professors taught me about how cytochrome p450 acts as an important enzyme for drug interactions – but we had little to no information about sub-types. The medical field was just becoming aware of HIV and its devastating effects. There were no “mAb” drugs. And I’m not even sure that genomics was a recognized term!

Contrast that with our keynote speaker Michio Kaku yesterday who, in talking about the future, noted the potential uses of 3-D printing in medicine. In just a few years, the ability to print personalized medications will be a reality.

The pace of change in our world today is so fast that it’s almost intimidating. Nevertheless, we must learn to adapt — and adapt quickly — or we risk becoming dinosaurs. And we all know what happened to them!

So, how do we maintain our clinical excellence… our ability to justify our actions to an interested third party? A personalized plan for continuous professional development or CPD is essential. To do this, start with an objective and thoughtful self-reflection. Seek feedback from a trusted colleague or mentor. After preparing your self-improvement plan, be sure to hold yourself accountable for making it happen.

Now, this can definitely be a challenging process. But the rewards — for you, your patients, and your colleagues — are well worth the effort.

So, I’ve talked about accountability, collaboration, and excellence as three of the four constructs of pharmacy’s True North. But I can’t leave out the one thing that will help power us on this exciting professional journey — leadership.

Leadership is an opportunity. I believe strongly that every single one of us can be a leader in our own right.

Leadership is not granted. It doesn’t come with a promotion. It doesn’t automatically happen at the upper echelons of practice, such as in pharmacy administration offices or at the C-suite level. Leadership is an opportunity. I believe strongly that every single one of us can be a leader in our own right.

I urge you to ask yourself, “What are the areas within my sphere of influence and scope of practice that I can change to improve patient care?” Where can I make a difference? How can I lead the way to better patient care?

THAT is leadership.

And, if we find ourselves in positions of formal leadership, then:

  • We must quantify the value that we bring to patients and share this information with administrators and payers.
  • We must expand our practice sites to include transitions of care and ambulatory care practice.
  • We must embrace the changing demographics of pharmacy and develop insight into the value of leadership style based on gender or generational differences.
  • We must establish a vision of where we’re going as a profession by encouraging our staff members to adapt to change, to be accountable, to collaborate, and to seek excellence.
  • And we must know how to effectively collaborate with the many leaders outside of pharmacy, knowing when to push and when to pull back.

If we strive to reach these goals, we will start to see extraordinary results for our patients and for ourselves as practitioners.

As author Jim Collins says, “The good-to-great leaders never wanted to become larger-than-life heroes. They never aspired to be put on a pedestal or become unreachable icons. They were seemingly ordinary people quietly producing extraordinary results.”

I know many pharmacists who are “seemingly ordinary people” who are constantly and quietly “producing extraordinary results.” Let’s start shouting those results from the rooftops!

What will be your role in the future of patient care and the pharmacy profession? Moving out of our collective comfort zones can be challenging, frightening, and even painful. But accepting the status quo will inevitably lead to our personal and professional stagnation. We must not be satisfied because we have so much to offer. Our patients need what we know.

The future requires all of us to lead through accountability, collaboration, and excellence.

Conclusion

We must accept accountability for our patient outcomes, both positive and negative. We must embrace new roles as collaborative members of the healthcare team by moving beyond a pharmacy-centric perspective. We must be willing to demonstrate our commitment to professional excellence by becoming board certified and by committing to Continuous Professional Development.

And, finally, we must all seek out opportunities to lead the medication-use and patient care policies, approaches, and initiatives within our practice settings.

This profession that we’ve chosen is a challenging one. We face obstacles of all kinds on the road to better patient care. But we will find our True North and achieve our goals, if we become accountable, if we learn to collaborate fully, if we achieve excellence in our professional knowledge and work, and if we embrace opportunities to lead.

I look forward to working with you as we continue our professional journey together. Thank you!

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  • Tom Devlin

    Congratulations Lisa! I have been a hospital pharmacist for 24 of the 32 years since I graduated with you way back in 1984 from IOWA! The Class of ’84 is proud of you!