ASHP InterSections ASHP InterSections

September 25, 2013

HENs Offer Opportunities for Pharmacists to Improve Patient Care

 

Hospital Engagement Networks are bringing together pharmacists, physicians, and nurses to improve patient outcomes in areas such as preventable infections, adverse drug events, and preventable readmissions.

A COLLABORATION BETWEEN ASHP and the American Hospital Association is yielding exciting opportunities for pharmacists to improve patient care across the country.

The two organizations are working together to increase pharmacist participation in Hospital Engagement Networks (HENs), part of the Centers for Medicare & Medicaid Services’ (CMS’s) Partnership for Patients program.

Approximately 3,700 hospitals participate in HENs, choosing among 10 areas in which to improve quality measures, including surgical site infections, adverse drug events, central line-associated bloodstream infections, venous thromboembolism, catheter-associated urinary tract infections, ventilator-associated pneumonia, and preventable readmissions.

The hospitals then share their successes with partnering organizations to help others replicate what they have achieved.

Pharmacists are a Natural Fit

Because so many of the primary goals for HENs involve medication therapy, pharmacists are in a perfect position to help as medication experts on the health care team. And when the American Hospital Association’s Health Research and Educational Trust (HRET) received a CMS grant to create a HEN, approaching ASHP seemed like a no-brainer.

The HRET HEN is focused on identifying solutions that are already reducing health care-acquired conditions and disseminating them to other hospitals and health care providers, according to David G. Schulke, HRET’s vice president of research programs in Washington, D.C.

“It was natural to reach out to ASHP because many readmissions are attributable to breakdowns in drug therapy, and pharmacists are well-trained and have tremendous knowledge in that area,” Schulke said. “I’ve worked with pharmacists and ASHP for many years, and HRET wanted to see if we could use that existing relationship to knit pharmacists into the HEN’s implementation teams.”

Beverly L. Black, MHSA, CAE

Beverly L. Black, MHSA, CAE

ASHP then turned to its strong network of state affiliates to reach members who might be interested in participating.

“Depending on what a state affiliate is focusing on, they may be able to recruit pharmacists to get involved,” said Beverly L. Black, MHSA, CAE, ASHP’s director of affiliate relations. She added that pharmacists attend workshops as presenters or participants, work within their health systems to design and implement quality improvement programs as part of the HEN, and forge strong partnerships among state health-system pharmacy groups and state hospital associations.

“These relationships are important because we are common stakeholders in ensuring that patients receive optimal therapy.”

Narrowing the Focus

Developing initiatives relevant to a hospital’s or health system’s needs, measuring outcomes, and sharing information with other providers in the network are major facets of the HRET HEN.

At Purdue University’s Center for Medication Safety Advancement in Indiana, pharmacists collaborated with the Indiana Hospital Association to create the Indiana Medication Safety Alliance. Last November, the Alliance hosted a conference about medication safety, ADEs and readmissions. Now the group has its own website, provides ongoing coaching, and hosts conference calls every other month or so.

The group initially focused on two measures, successful anticoagulation with warfarin and avoidance of hypoglycemia among insulin users, but has since whittled its efforts down to improving anticoagulation.

John B. Hertig, Pharm.D., M.S.

John B. Hertig, Pharm.D., M.S.

Narrowing the focus was essential because the HEN’s guidance offers so many possible areas for improvement, said John B. Hertig, Pharm.D., M.S., the Center’s associate director.

“The HRET HEN’s Encyclopedia of Measures contains more than 100 distinct measures. So, zeroing in on warfarin was a strategic decision because the HEN was looking at patient harm with regard to ADEs and the hospitals in Indiana were reporting [issues with anticoagulation] more than anything else,” Hertig said.

At the University of Arkansas for Medical Sciences in Little Rock, the focus is on reducing readmissions for heart failure patients.

“When Medicaid announced penalties for pneumonia, acute myocardial infarction, and heart failure, we decided to take a look at how that would affect us,” said Niki Carver, Pharm.D., assistant director of pharmacy.

“After working on medication reconciliation for years, I wondered if there was a way the pharmacy could be notified when heart failure patients were admitted so the pharmacy could obtain medication histories for those patients.”

Carver knew such an effort would have an impact on the pharmacy’s workload, so she created an elective rotation for fourth-year pharmacy students that tasks them with obtaining medication histories and assisting in quality improvement efforts. Thus far, reductions in monthly readmission rates for patients with congestive heart failure have ranged from 1.67 to 4.43 percent.

Pharmacists at The Johns Hopkins Hospital are working to improve HCAHPS scores related to educating patients about their medicines. Above, a pharmacist talks to a patient about how to properly use an insulin pen.

Above left, Leigh Efird, Pharm.D., BCPS, clinical pharmacy specialist, The Johns Hopkins Hospital, teaches a patient how to properly use an insulin pen.

Working Smarter, Not Harder

The Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) served as a catalyst for involving pharmacists in the HRET HEN at The Johns Hopkins Hospital in Baltimore, where their goal is to improve HCAHPS scores for medication-related questions.

“When we partnered with the Maryland Hospital Association, they knew we were working on issues related to HCAHPS,” said Meghan Davlin Swarthout, Pharm.D., MBA, BCPS, division director, ambulatory and care transitions.

“We were able to take actionable steps toward our goals and share information with other hospitals about our successes.”

Swarthout said that the hospital has increased its “Always” HCAHPS score from the 48th percentile in the second quarter of FY2013 to the 84th percentile in the fourth quarter for the survey question, “When I left the hospital, I clearly understood the purpose for taking each of my medications.”

Swarthout also stressed the value of sharing information within the network. “Sometimes the goals for quality and safety can be overwhelming. HENs bring in the expertise of your peers, and they can help you target your biggest problems,” she said.

Carver noted that HENs eliminate redundancy. “You hear what other hospitals have done, take what you need for your institution, make changes that fit your setting and implement them, instead of starting something from scratch.”

Pharmacist involvement in the HRET HEN is still fairly sporadic. For example, in a statewide workshop of roughly 250 attendees that Swarthout attended, only about 10 participants were pharmacists. Yet despite the relatively small number of pharmacists there, they made an impact: Once the other participants heard what the pharmacists had to say about safe medication use, many indicated they would promote better use of pharmacists’ skill within their own institutions.

ASHP is hopeful that by encouraging affiliate members to participate in the state-level HENS, other health systems will likewise more fully understand the valuable role that pharmacists play in ensuring patient safety and optimal health outcomes.

“We believe that if more pharmacists knew the benefits of participating in the HENs network, they would be more interested in participating,” Swarthout said. “We all have days when it feels like we’re not making any improvements, and that can be discouraging. But when you hear other people in the HEN talk about the same things, you realize you are not alone. You come away with ideas and external motivation.”

Showcasing Pharmacists’ Skills

HENs are also an excellent way to advance the profession, according to Hertig.

“It’s an opportunity for pharmacists to showcase their skills and abilities as members of interdisciplinary teams,” he said. “But it’s also in line with ASHP’s Pharmacy Practice Model Initiative in that it helps pharmacists work at the top of their licenses. What better avenue to show the impact we can have than a federal program where we work with nurses, physicians, and other professionals?”

Shekhar Mehta, Pharm.D., M.S.

Shekhar Mehta, Pharm.D., M.S.

Shekhar Mehta, Pharm.D., M.S., ASHP’s director of clinical guidelines and quality improvement, agreed.

“ASHP is primarily concerned with patient care, medication-use safety, and ensuring that pharmacists are part of a collaborative care team. So, this initiative supports all those goals,” he said.

“Pharmacists are also the most knowledgeable members of the team when it comes to medication use, and that’s a big issue in health care reform in improving the quality of care and lowering readmissions.”

Ultimately, patients are the ones who benefit most, said Carver.

“Skeptics will say that it’s more work for pharmacists, and it is. But if you’re in hospital pharmacy, you’re in it to improve patient care. And the outcomes you will see with this program are astounding.”

—Terri D’Arrigo

Editor’s Note: Interested in getting involved with an HRET HEN program? Send an email to affiliates@ashp.org, and we’ll put you in touch with the right resources within your state.

 

July 30, 2013

Compounding Legislation: Your Voice Urgently Needed Now!

Filed under: Current Issue,From the CEO,Quality,Regulation — Tags: , , , , — jmilford @ 12:29 pm
Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

It’s hard to believe that after the many deaths and illnesses associated with the alleged practices at the New England Compounding Center last Fall, the bipartisan Senate bill (S.959) that is designed to prevent a tragic repeat could be facing tremendous opposition.

ASHP strongly supports this legislation. Yet, it appears that opposition to the Senate bill is forming, because certain interests want to protect the status quo, which we believe could be at the expense of protecting patients from another compounding tragedy.

These special interests are also threatening to severely limit how pharmacists in hospitals and health systems serve and protect patients. ASHP supports the provision in the bill that exempts health systems from being designated as compounding manufacturers. Without this important exemption, many hospitals and health systems would have to register with the Food and Drug Administration (FDA) as compounding manufacturers, since anticipatory compounding is required for us to meet the needs of our sickest and most vulnerable patients.  Also, without the exemption, many hospitals would not be able to prepare compounded preparations and send them to their wholly owned outpatient clinics, surgery centers, smaller inpatient facilities, and medical office practices.   This is a critical distinction, based on the fact that hospitals and health systems are fully accountable for the comprehensive care of the patient – as compared to a compounding manufacturer that sells its products across state lines without a prescription or knowledge of the patient to a third party for administration.

This distinction between health systems and compounding manufacturers is based on very important differences:

  • Hospitals and health systems have well-established quality improvement, infection control, and risk management committees, as well as adverse event monitoring and reporting systems.
  • Health systems must comply with the Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation and are accredited by quality improvement organizations such as The Joint Commission and DNV Healthcare, both of whom have deemed status with CMS.
  • Hospitals and health systems have Pharmacy and Therapeutics Committees that control approved drug formularies.

We must protect the important work that pharmacists do in hospitals and health systems to take care of their patients.  In addition, hospital pharmacists and other providers must be assured that when they need to purchase compounded products from outside suppliers that they can expect to receive products that are safe and effective for their patients.  Therefore, we must enact into law urgently needed regulatory control over compounding manufacturers to prevent another tragedy.

You can make a difference. Your voice really matters to your elected Senators and Representatives in Congress!

ASHP has made it as easy as just a few clicks on your computer for your voice to be heard.

Go to ASHP’s advocacy page and make a difference for patient safety!

Tell your Senators that you want them to vote “YES” in support of S. 959.  This legislation creates a new category, “compounding manufacturer,” which will be regulated by the FDA. Hospitals and health systems are considered traditional compounders in the legislation and will remain under the purview of state boards of pharmacy and other accrediting bodies.

Tell your Representative that the House should take a similar approach to the legislation and give the FDA the tools it needs to prevent another tragedy.

Your support today can go a long way in getting this important legislation passed!

July 22, 2013

Interprofessional Collaboration: ASHP’s Response to the AMA

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

In June of this year, the American Medical Association (AMA) passed a resolution that caused concern among many of us.  At first glance, it’s no wonder why the policy gave us pause, as it states that “a pharmacist who makes inappropriate queries on a physician’s rationale behind a prescription, diagnosis, or treatment plan is interfering with the practice of medicine.”

While this statement seems to throw up a barrier to the good, productive collaborative relationships that best benefit patients–and that pharmacists, physicians, and patients have all grown to appreciate–it’s important to look at what was at its root: this nation’s drug abuse problem.  The AMA’s statement is a response to the efforts of some pharmacies in light of the federal government’s stepped-up enforcement to prevent diversion and better control the epidemic of prescription drug abuse.

Certain pharmacies, in response to enhanced scrutiny and enforcement efforts by the Drug Enforcement Administration, are calling and faxing to verify the legitimacy of every controlled substance prescription before filling. The burden this has placed on some physicians’ offices gave rise to this new AMA policy.

I recently wrote a letter to the CEO of the AMA that stressed the long history of collaboration that exists between pharmacists and physicians in hospitals, health systems, and ambulatory clinics. My letter confirmed that ASHP would be pleased to work with the AMA and other stakeholders to find solutions to the broader problem of prescription drug abuse, which ideally would include more effective communications and interprofessional collaboration among pharmacists, physicians, other health care providers, policymakers, and law enforcement.

The nature of today’s health care delivery system depends on professional collaboration to make sure our patients are getting the best health care possible.  Over the course of my 35-plus years in practice, and here at ASHP, I’ve seen firsthand how that collaboration has grown exponentially,  and is now widespread, not only in our nation’s hospitals and clinics, but with our community pharmacy partners.

And, indeed, we hear the same from our physician colleagues. In fact, Richard Pieters, M.D., the physician who wrote the draft for the AMA resolution, described his working relationship with pharmacists as “excellent” in an interview with Pharmacy Practice News. He added that “pharmacists are very valuable members of the team.”

Pieters, who is a radiation oncologist at the University of Massachusetts Medical Center and president-elect of the Massachusetts Medical Society, went on to state that, as a physician who is board-certified in hospice and palliative medicine, he finds pharmacists to be “fantastic resources.”

With a strong commitment to getting to the right issues in the right ways, pharmacists and physicians can both be part of the solution to our nation’s epidemic of prescription drug abuse in a way that encourages the interprofessional collaboration that best serves our patients.

June 4, 2013

Courage

Gerald E. Meyer, Pharm.D., MBA, FASHP

Editor’s Note: The following inaugural address was given by new ASHP President Gerald E. Meyer, Pharm.D., MBA, FASHP, at the Opening Session of ASHP’s Summer Meeting in Minneapolis, Minn.,  June 4, 2013. Dr. Meyer is director of experiential education, Jefferson School of Pharmacy, Philadelphia. His full address will appear in the August 15 issue of the American Journal of Health-System Pharmacy. To watch the speech in its entirety, click here.

GOOD MORNING, AND THANK YOU for that warm welcome!

I would like to begin by acknowledging you—our members. I want to personally thank all of the members who have participated in ASHP’s state societies.

ASHP could not fulfill its mission without the support and inspired leadership of our affiliates. Yes, being president of ASHP involves a lot of time and travel. But, it also comes with a large support staff.

Local volunteer leaders, on the other hand, do it all. You are the membership committee, the program committee, the finance committee, and the professional advocacy committee. So, to all of you, a great big thanks!

A Rich Pharmacy History

Many of you may know that I am from Philadelphia. And I am proud of it.

Philadelphia has a very rich pharmacy history. We have the first hospital in the United States—Pennsylvania Hospital, founded by Benjamin Franklin in 1751. We have the first college of pharmacy in the United States—the Philadelphia College of Pharmacy, which opened in 1821. And we had the first hospital pharmacist in the United States—no, not me. His name was Jonathan Roberts.

We also lay claim to the first Hospital Pharmacy Residency Program to be surveyed for ASHP accreditation and the first accredited Pharmacy Technician Training Program–both at Thomas Jefferson University Hospital.

We have four past-presidents of ASHP currently working in Philadelphia and a fifth in retirement nearby. I won’t tell you who they are—that’s a quiz.

I have been truly fortunate to have had access to so many health-system pharmacy leaders. They, together with many other professional colleagues, have been invaluable as I charted a course through my career. And, of course, I have the most wonderful personal support from my wife, Cheryl, and my family.

I want to extend my personal thanks to all of them for their encouragement and support.

Top Priorities

In writing this speech, I definitely had a lot of people to call upon. Yet, as much as I value their wisdom, I did not ask a single one of them for guidance on what I should talk about today.

Rather, I asked you, the members. ASHP is a membership organization. It is owned by you, its members. So I felt it was appropriate to focus our discussion today on those issues that are of greatest importance to you.

We sent out a survey to a random sample of ASHP members and asked: “What question would you like to ask Gerry Meyer?” Well, you did not disappoint. We received 130 questions, many of which spoke to the concept of courage. So, settle back and relax. This may take awhile. (OK, for the sake of time, we did narrow it down a bit.)

For our first question, Fred Bender, Pharm.D., FASHP, director of pharmacy services at Greenville Health System in Greenville, S.C., asked, “What will be your top priorities as incoming president of ASHP?”

Fred, I have a list of priorities to share with you. But my priorities are of little value unless they become our priorities. My top priority, therefore, is to be the best leader I can possibly be. And you can’t lead without a vision. So, let’s start there.

What makes a good leader?

  • The ability to articulate a vision,
  • The ability to motivate others toward that vision, and
  • The ability to remove obstacles to promote achievement of the vision.

Now, who among you can recite ASHP’s vision? ASHP’s vision is that medication use will be optimal, safe and effective for all people, all of the time. There’s no mention of “hospitals” or “health systems.” There’s not even mention of “patients.” It says “all people, all of the time.”

So, Fred, here is my list of priorities for the year. I would suggest that we view most of the individual items on this list as obstacles confronting us in our efforts to accomplish ASHP’s vision:

  • Build coalitions,
  • Implement the recommendations of the Pharmacy Practice Model Initiative,
  • Pursue provider status,
  • Promote interprofessional education and practice,
  • Expand training and certification for pharmacists and pharmacy technicians,
  • Position ASHP to be as nimble as possible in a rapidly changing environment, and…
  • World peace!

I’m somewhat serious about that last item on the list. Creating an environment in which medication use will be optimal, safe and effective for all people, all of the time is a bold and expansive vision. And just because it is hard to conceptualize, we cannot be deterred from putting our energies towards its achievement. (So, in that respect, our vision is a bit like world peace.)

Becoming Strong Advocates for Patients, Profession

Kevin Aloysius, who just graduated with his Pharm.D. last month from Texas Tech University Health Sciences Center, in Lubbock, (congratulations to all new graduates, by the way!), asked the next question: “How do we prevent doctors’ comments such as, ‘Well, if you wanted to give me recommendations on how to treat a patient, why didn’t you go to medical school?’ “

Kevin, there is a serious answer to your question, but if I wanted to be flippant, I’d say to the physician in question: “If you wanted to be a medication-use expert, why didn’t you go to pharmacy school?” That is an accurate, patient-centric response, isn’t it? A pharmacist’s unique education focuses on the optimal, safe and effective use of medication for all people, all of the time.

Having said that, let’s remember that physicians build their reputations on high-quality outcomes. Why, then, don’t physicians seek the counsel of pharmacists in all matters of medication use? After all, the rate of medication misadventures in the current system is well-documented and not acceptable.

I believe their hesitancy relates to the element of trust. Physicians trust pharmacists to prepare and dispense medications accurately. They trust pharmacists to offer advice on proper administration. They expect pharmacists to offer suggestions on medication compatibility and dosage adjustments.

But, some may not trust pharmacists to create optimal, safe and effective medication-use plans for all people, all of the time. How, then, do we build this trust?

We must aggressively pursue all avenues to modify the perceptions of physicians. And not just physicians, but also health care policy makers, decision makers, and providers, as well as  the general public about the unique education and training possessed by pharmacists. We must have the courage to be strong advocates for our patients and for our profession. Historically, we have been far too passive in promoting our value.

Antagonism vs. Synergism

Our next question comes from Jamie Ridley Klucken, Pharm.D., MBA, BCPS, an assistant professor of pharmacy practice at Shenandoah University, Ashburn, Va., who asked, “We see a push to work collaboratively with other health care providers but seem to have a difficult time putting this into practice. Are there ways to accelerate this interprofessional practice? Perhaps through pharmacy education and post-graduate residency programs?”

Jamie, by definition, interprofessional activities cannot be accomplished by one profession. Each profession must be willing to participate.

The good news is that in May 2011, a group called the Interprofessional Education Collaborative—consisting of educators representing pharmacy, medicine, nursing, dentistry, and public health—released a report that summarized the core competencies needed for interprofessional collaborative practice. Those core competencies fell within four domains:

  • Values and ethics,
  • Roles and responsibilities,
  • Interprofessional communication, and
  • Teams and teamwork.

What this report says is that to build an efficient and effective health care system, health care providers need to:

  • Have a common understanding of health care ethics and values,
  • Understand one another’s roles and responsibilities,
  • Learn how to communicate with one another, and
  • Learn how to be part of effective teams and how to play well together in the sandbox.

For two years, we have had this guidance document that delineates the curricular components that should be taught to health care students, interprofessionally. Jamie, I agree with you. Our profession needs to take a leadership position in incorporating interprofessional competencies into our formal education and training standards. These changes cannot occur fast enough.

Furthermore, to develop this set of skills and knowledge within practicing pharmacists, ASHP must incorporate this critical content within our continuing professional development offerings.

It’s important to consider what this report does not say. Nowhere does it say that interprofessional education should encompass getting health care students into the same classroom to teach them pathophysiology, pharmacology, diagnosis, or treatment. So, if those are not our commonalities, then those must be our differences. Exactly.

Let’s look at this in pharmacologic terms. Sometimes, we administer two very effective drugs that may compete for the same receptor, and the result is that they become less effective. We call that phenomenon “antagonism.” On the other hand, sometimes we prescribe two drugs and the positive effect is greater than the anticipated sum of their individual effects. We call that “synergism.”

Let’s move past interprofessional antagonism. Let’s have the courage to promote an efficient and effective health care system comprised of interdependent, synergistic health care providers.

Practicing at the Top of Our Education, Training

The next question comes from Cassie Heffern, Pharm.D., a PGY2 ambulatory care resident with CoxHealth, in Springfield, Mo., who asked: “In some more rural hospitals, change is almost feared. Despite [the fact] that no one will lose a position by  including more PPMI, the subject is still feared. How would you suggest to keep moving forward with PPMI?”

As you may know, ASHP’s Pharmacy Practice Model Initiative—or PPMI—envisions a future in which pharmacists practice at the top of their education and training. The model identifies the roles that pharmacists must assume and then describes the need to maximize the incorporation of enablers—notably, technicians and technology—to help achieve those roles.

Earlier, I stated that leadership encompasses stating a vision, engaging others to embrace the vision, and removing obstacles toward accomplishing the vision.

For 71 years, ASHP has been a leadership organization. This professional leadership continues. Through the PPMI, ASHP members created a bold vision, and ASHP is committing significant resources to help our members achieve their vision.

Cassie, your question alluded to challenges faced by rural health care providers. We recognize that many of our members are not able to leave their workplace to attend live educational offerings. We have begun, and will continue to accelerate, the delivery of educational programming in formats that offer accessibility to all of our members.

The PPMI envisions advancing pharmacy practice beyond pharmacists offering recommendations for others to implement. It envisions pharmacists as interdependent prescribers who accept accountability for the patient-care plans that they personally initiate.

The willingness to expand our scope of accountability to improve our patients’ health is the essence of our envisioned pharmacy practice model. Are we prepared to expand our scope of practice? Are we prepared to accept accountability for prescribing decisions?

Doing so requires courage. It requires the courage to challenge the status quo. It requires the courage to practice at the top of our education and training, not just at the top of our licenses. It requires the courage to practice beyond the borders of established practice.

The Future of Residency Training

Among the questions I received, more related to residencies than to any other topic. Two members, Kent Montierth, Pharm.D., director of pharmacy for Banner Estrella Medical Center, in Phoenix, Ariz., and Erica Maceira, Pharm.D., BCPS, CACP, clinical pharmacy specialist and student and resident coordinator at Albany Medical Center Hospital in Albany, N.Y., asked: “How does ASHP plan to help grow the number of residency programs and the number of available positions? And, how can the accreditation process be simplified?”

Although it sometimes may feel like we are making little progress in this area, the numbers tell a different story. From 1995 to 2006 (a 12-year period), the number of available accredited residency programs and the number of available positions in those programs doubled. From 2006 to 2012 (a subsequent six-year period), the number of accredited residency programs and number of positions doubled again.

Part of the reason for this rapid growth is that the value proposition for residencies is easily developed for residents,  employers, patients, and the profession. The ASHP website contains a number of documents that can assist practitioners in justifying, designing, and conducting residency training programs.

However, one of the greatest barriers to increasing the number of residency training programs cannot be overcome with guidance documents  alone. A good training program requires a solid infrastructure.

Pharmacy services must meet contemporary standards of practice. Preceptors must have the ability to impart knowledge and develop critical reasoning skills. Residency program directors must be able to mentor and  inspire those entering the profession. And an organization’s culture must be supportive of the training mission.

We cannot, and we should not, compromise on these foundational pillars.

There are now more than 1,000 residency programs in the United States that have a solid infrastructure. I call on those programs to consider expanding. For those institutions without a sufficient infrastructure currently in place, consider collaborating with an existing residency program.

In the 1970s, and then again in the 1990s, my institution offered joint residency positions with neighboring institutions. Those joint programs continued until our partners had developed sufficient infrastructure to conduct their residencies independently.

Kent and Erica, you also asked about simplifying the accreditation process. I agree that we must critically evaluate the current standards to ensure that each requirement contributes to the quality of the training process.

Both the PGY1 and PGY2 standards for accreditation are currently under revision, which presents us with just such an opportunity. As drafts of proposed revisions to those standards are circulated, I encourage all residency program directors to provide your feedback.

Many of the questions I received about residency training referred to ASHP’s member-developed policy that, by 2020, all pharmacists involved in direct patient care must complete a residency.

Let me be clear. Residency training is a critical element in enhancing patient care by expanding pharmacists’ responsibilities. Residencies instill the confidence in young practitioners to have the courage to drive the profession past its current borders.

Please remember that ASHP’s residency policy is aspirational in nature. The decision about whether to pursue a residency is  a career decision. You do not need a residency to obtain a pharmacist license. But you do need a residency to pursue and advance along certain career paths, and the number of those career paths continues to grow every year.

There are four stages to the education and continued training of a pharmacist: pre-pharmacy undergraduate education, professional doctorate education, formalized training, and continuing professional development.

Coordinating the outcomes of each of these four stages is a professional imperative. While the requirements for the pre-pharmacy and pharmacy curricula will evolve, we must recognize that there is only so much that we can accomplish in the classroom because (1) contact time is limited, and (2) students do not have pharmacist licenses.

At some point in time, the profession will need to address the question: Should residency training be required for pharmacists to meet their obligation to  their patients? At some point, that answer will be “yes.” Whether this happens by 2020 or not, it is far better for the profession to prepare for that future than to be unprepared when that future arrives.

Gaining Provider Status

Zina Gugkaeva, Pharm.D., a PGY1 resident at the University of Iowa Hospitals and Clinics, in Iowa City, asked our sixth and final question: “When are pharmacists finally going to be recognized as providers, and what will it change?”

Many of you may have attended the Provider Status Town Hall at this Summer Meeting where this very issue was discussed. Much of what we heard, we already knew:

  • The health care environment is changing.
  • Emerging practice models are focused on integrated health care delivery systems.
  • Policymakers are seeking ways to make health care more affordable for more people.
  • Payment will be focused on quality, not quantity, of care.
  • Consumers will demand transparency in the cost of their care.

So, what will happen when pharmacists are recognized as health care providers?

  • Pharmacists’ patient care services will improve access.
  • Pharmacists’ patient care services will improve quality.
  • Pharmacists’ patient care services will help control costs.

Access—quality—cost. There is substantial documentation to support the positive impact of pharmacists on access, quality and cost of care. We know it. Now we have to sell it. We must have the courage of our convictions.

The first step is to ensure that the profession moves forward with this common message by solidifying these basic principles within the existing coalition of pharmacy organizations. Then, we need to expand the coalition to include other critical stakeholders, including health care provider groups, payers, and patient advocates. We need to draft legislation and seek support by educating legislators, both on a state and national level.

ASHP will serve as your collective voice in formulating the message. ASHP will develop the materials needed to deliver that message. ASHP will tailor those materials for different audiences. And ASHP will train you.

But, we need you to deliver the message to your legislators, to your C-suite, to your health-system’s lobbyists, to your health care colleagues, to your complacent pharmacist colleagues, to your local media, and to your patients.

Access—quality—cost. The message is clear. The message is focused. The message meets society’s needs.

Gaining provider status will ensure that pharmacy is at the table when regulators and other policymakers invite health care providers to help construct new delivery models. And that is why ASHP, the American Pharmacists Association (APhA), the American College of Clinical Pharmacy (ACCP), and other health care organizations have committed significant resources to achieving provider status for pharmacists.

Zina, while no one can predict when we will finally succeed, I am confident that we will succeed if we have the courage to stand strong and united on this issue and if our members get personally involved.

I call upon all pharmacists who believe they are health care providers, on all student pharmacists who believe they are training to become health care providers, on all people who want their medication use to be optimal, safe and effective all of the time. I call on everyone to send the message: “Pharmacists are medication-use experts. Pharmacists improve access, improve quality, and control the cost of health care. Pharmacists are health care providers.”

In closing, I want to thank everyone who took the time to submit questions. I invite you to continue to send me your comments and suggestions over the next year. Finally, I want to thank you for the courage you show every day toward advancing ASHP’s vision: that medication use will be optimal, safe and effective for all people, all of the time.

Thank you.

April 30, 2013

New Strategic Plan Points the Way Forward

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

A GOOD STRATEGIC PLAN allows us to map our future with a clear course to success. In January of this year, the ASHP Board of Directors approved a new comprehensive Strategic Plan.

This plan is a significant departure from the Leadership Agenda that it replaces because it includes and integrates all ASHP activities and operations. While the previous document focused only on professional priorities, our new Strategic Plan includes three main pillars: Our Patients and Their Care, Our Members and Partners, and Our People and Performance.

This new plan embodies our passion, our energy, and our unwavering commitment to you–our members–and the patients whom you serve.

We began the process of creating this comprehensive Strategic Plan by starting with a new vision statement for ASHP. Working with a great team of Board members, Section and Forum Executive Committee leaders, and ASHP staff at an April 2012 retreat, we strove to develop a new vision that would be bold, far-reaching and important to our members and patients.

In particular, we wanted to create a vision that is universal in focus and covers all patients in all settings across the continuum of care. I am pleased to say that our new vision statement achieves this important goal:

ASHP’s vision is that medication use will be optimal, safe and effective for all people, all of the time.

Working from our new vision statement, we turned to revising our mission. Again, we focused on pharmacists’ role in the full spectrum of individual and public health. We wanted to craft a mission statement that moved beyond medications to emphasize that, in addition to treating disease, pharmacists have an important role in improving and maintaining health. Our new mission statement, below, also sets the stage for our member pharmacists as providers caring for and following patients through their entire healthcare experience, regardless of the site of care:

The mission of pharmacists is to help people achieve optimal health outcomes. ASHP helps its members achieve this mission by advocating and supporting the professional practice of pharmacists in hospitals, health systems, ambulatory clinics, and other settings spanning the full spectrum of medication use. ASHP serves its members as their collective voice on issues related to medication use and public health.

Drawing from the vision and mission, we created ambitious strategies, goals and objectives. As I mentioned above, the Strategic Plan includes three pillars, which are short and simple, yet all-encompassing, high-level strategies:

    1. Our Patients and Their Care
    2. Our Members and Partners
    3. Our People and Performance

The first pillar focuses on the central purpose of pharmacists: improving the health of our patients throughout the entire continuum of care, including both ambulatory and acute care. The goals and objectives within this strategy provide a roadmap for how ASHP helps its members care for their patients now and in the future. They include:

  • Improving patient outcomes from medications;
  • Wellness and preventative care;
  • Advancing pharmacy practice;
  • Helping the pharmacy workforce meet patient needs;
  • Providing professional development;
  • Advocating for laws, regulations, and standards; and
  • Placing an increasing emphasis on expanding our members’ practices in clinics and other ambulatory care settings.

Examples of activities in this realm include efforts related to improving care transitions, using information technology and pharmacy technicians more effectively, advancing efforts related to the Pharmacy Practice Model Initiative, ensuring an adequate supply of well-trained pharmacists, providing contemporary education and professional development, and advocating for changes in laws and regulations that give patients greater and more effective access to pharmacists.

The second pillar of our new Strategic Plan focuses on the central purpose of ASHP: our members. Members are the focus of our work and are the core of ASHP’s inspiration and reason for being. The goals and objectives of this pillar relate to how we serve our members and work with other stakeholders, including:

  • Maintaining a high level of member satisfaction,
  • Growing membership,
  • Supporting our state affiliates,
  • Engaging members through Sections and Forums,
  • Working in collaboration with our various partners in pharmacy and the broader healthcare community, and
  • Publishing timely and innovative resources.

Some examples of activities in this area include enhancing opportunities for members to participate and take leadership roles in ASHP; partnering with ASHP state affiliates on advocacy and other efforts to improve patient care; increasing the number of tools and resources to help our members best care for their patients; and fostering and growing relationships with pharmacy, medicine, nursing, consumer organizations, and others.

The third pillar focuses on a vital element to our success: our staff and organizational performance. ASHP can be proud of its strong staff team. Our staff is a critical success factor and an invaluable asset to the organization as we strive to meet and exceed our ambitious goals. This pillar’s goals include:

  • Fostering staff excellence, teamwork and innovation;
  • Ensuring a financially strong organization;
  • Maintaining effective and energized governance;
  • Effectively managing our organizational infrastructure; and
  • Fostering high-performance staff leadership.

The essence of this pillar and its related goals and objectives is that having the best staff in the business and a financially strong organization is central to the Society’s ability to continue to maintain and enhance the services that we provide to our members.

We are all very excited about the future this plan will help guide us to. We will use the Strategic Plan to direct all ASHP activites, focusing our work on the most important issues and services required by you and the patients you serve.

I encourage you to review the new ASHP Strategic Plan, share it with your colleagues, and use this plan as you engage in your own strategic planning efforts within your practice setting.

April 22, 2013

Boston Bombing Puts Hospital Pharmacies into Emergency Mode

Filed under: Current Issue,Feature Stories — Tags: , , , , , , — Kathy Biesecker @ 11:54 am

Ambulances line Columbus Avenue after two explosions went off near the finish line of the Boston Marathon April 15. Photo by David L. Ryan/Boston Globe via Getty Images

THE PEOPLE WHO ARRIVED in the emergency department on April 15, 2013, had injuries unlike any Nancy Balch had seen in her 12 years as an emergency department pharmacist at Massachusetts General Hospital in Boston. Their injuries were severe. At least one person had had a limb blown off.

“I’ve seen a lot, unfortunately,” she said of her decade-plus in emergency care at the level 1 trauma center, “but nothing like this.”

High Volume, Extensive Injuries

By the end of Balch’s regularly scheduled shift on Monday, the hospital had treated 29 people injured by the bombs that exploded near the finish line of the Boston Marathon.

People came to the emergency department the next day, too, Balch said. Some sought care because their hearing had not returned to normal. Others did not realize until Tuesday that they had a piece of metal stuck in them.

Shannon Manzi, at Boston Children’s Hospital, has spent almost as much time in an emergency department as Balch has.

“I have not seen these types of injuries since I was in Haiti,” said Manzi, who went there in 2010 immediately after the 7.0-magnitude earthquake.

But in Haiti, the patients had crush injuries, she said. On Monday, the patients at Boston Children’s had blast injuries. Both types of injuries can sever limbs.

The children hit by the blasts, however, had injuries more extensive than what Manzi had seen after the earthquake.

On Monday, Boston Children’s, a level 1 pediatric trauma center, received 10 patients from the blasts, the hospital has reported. Manzi said she had just torn down the medical tent at mile 15 in the marathon when her pager alerted her to a “mass casualty” at the hospital. The first two patients were in the emergency department when she arrived.

Good Decisions, Well-Made Plans

The bombs exploded about the same time as the overlap in day and evening shifts for emergency department pharmacists and pharmacy technicians, Manzi said.

On arrival, she assumed the role of managing pharmacist. Pharmacists with emergency department training who had been working upstairs in the hospital came downstairs to bring the total to six.

Shannon Manzi

Manzi said emergency care personnel organized into four teams, each with two physicians, two nurses, one clinical assistant, one respiratory therapist, and one pharmacist. She remained available to manage resources, ensure everyone had what they needed, communicate with the main pharmacy, and step in when a pharmacist needed relief. The sixth pharmacist worked with the patients who were in the emergency department for reasons other than the bomb explosions.

Brigham and Women’s Hospital, a level 1 trauma center next to Boston Children’s, received 31 patients from the explosions, an emergency department physician told CNN on Monday night. Nine of those patients underwent major surgery that day, he said.

Pharmacy services executive director William Churchill said his department’s immediate goal was to ensure that the physicians and nurses in the emergency department would not have to leave a bedside to obtain a medication. The pharmacy accomplished that goal by shifting resources to have six pharmacists in the emergency department in the initial hours after the explosions, he said.

One pharmacist was already in the emergency department for the evening shift. The day-shift emergency department pharmacist, Churchill said, stayed on, as did nearly all the staff.

And, “as luck would have it,” he said, several members of the “emergency department pharmacy team” were already on duty in other areas of the hospital. The pharmacy deployed two to each of the main areas of the emergency department. In each twosome, one spoke with the nurses and physicians to determine what they needed and answer questions and the other pharmacist expedited medication delivery.

“We drill a lot with preparing for disasters and mass casualties,” Churchill said.

In those types of emergencies, patients may need a medication before they have a medical record number or their name is known. Lacking that information, he said, personnel other than the pharmacists can have trouble obtaining a medication from an automated dispensing machine. So the pharmacy on Monday deployed pharmacists who could obtain medications quickly from automated technology, he said. Those pharmacists also facilitated the preparation and delivery of preoperative i.v. drug doses for the patients heading for surgery.

“One of the pharmacists said to me that it was her perception that . . . the nurses seemed to be relieved that the pharmacists were there as part of the team helping them,” Churchill said. All of this transpired while he was offsite.

John Fanikos, one of the pharmacy’s senior directors, assumed the role of the pharmacy unit leader and went to the hospital’s command center, Churchill said. “We’ve actually drilled and practiced that with all of my senior directors.”

With Fanikos in the hospital’s command center, Churchill said, two of the mid-level managers took roles in operating the pharmacy command center.

Contingencies

Erasmo “Ray” Mitrano

At Massachusetts General, interim chief pharmacy officer Erasmo “Ray” Mitrano made sure Balch had support in the emergency department—another pharmacist who could lend a hand and provide care to pediatric patients if any arrived.

Mitrano sent Lois Parker to the emergency department from the pediatric intensive care unit. He also had pharmacists elsewhere in the hospital remotely handle the workload that would have been Balch’s on a normal day. This, he said, freed up Balch and Parker to focus on the patients injured by the bombs.

Parker said she stayed in the pediatric emergency department to be out of the way until her assistance was needed. But no pediatric patients had arrived by 5:30 p.m., she said, when the hospital’s incident command center sent a broadcast e-mail stating that staff coverage was adequate enough for the day shift to leave. She checked with Balch, who concurred that Parker could leave.

Parker said she felt “pretty prepared” for the situation in the emergency department. The hospital has conducted disaster drills on a regular basis, and she participated in a tabletop disaster drill that was specifically geared toward pediatrics.

Emotional Support

The day after the bombs exploded, Manzi said, Boston Children’s held a debriefing for emergency department personnel. She said the hospital commonly holds a debriefing after a bad outcome. But the recent debriefing was held for another reason. The injuries on Monday were not the type seen every day, she said.

“When it’s in your background and it’s terrorism,” Manzi said, “it’s a different thing than when it was a very, very sad case of a motor vehicle accident or a shaken baby.”

Churchill estimated that 50-some pharmacists were at “The Brigham” when the bombs exploded. “People rolled up their sleeves and volunteered to stay and did whatever was necessary to get it done,” he said. “I couldn’t be more proud of that situation or my department.”

When interviewed two days after the bombing, Churchill said he continues to check on how his staff members are doing. “Hopefully, everybody’s going to do real well,” he said.

Parker, who said she was not directly involved in caring for any of the injured, said the bombing hit particularly “close to home” because coworkers could have been among the injured. “The Mass General has a fairly sizable team of people who run in the marathon, and they raise money for various programs at the hospital, including the pediatric oncology clinic,” she said.

Word of the bombing reached Parker soon after she and others had determined through the marathon organizer’s athlete tracking system that some of their colleagues were near the finish line. Balch said she sees “awful accidents” all the time, yet what she saw April 15 was different.

“The thing that most struck me,” she said, “is it was something that somebody did to people. . . . That’s what makes it most horrific for me.”

Three hours after the bombing, the Boston Police Department reported that three people had died. Local hospitals had received 176 people by 7 a.m. Tuesday, the department later stated.

–By Cheryl Thompson; reprinted with permission from ASHP News.

 

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