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March 28, 2012

Pharmacists Moving into New Management Roles

Thomas J. Johnson, Pharm.D., MBA, BCPS, FASHP, FCCM

Thomas J. Johnson, Pharm.D., MBA, BCPS, FASHP, FCCM

A LITTLE OVER A YEAR AGO, I transitioned from a clinical faculty role to being a director of a hospital pharmacy department. I quickly found that the clinical skills in critical care that I had developed over the first dozen or so years of my career either applied just a little bit or not at all. Obviously, many of the people skills carried over, but I found that the day-to-day sense of immediate success or failure I had previously observed in the intensive care unit had little in common with my new job. Now I needed to evaluate programs and make changes over the span of weeks, months and years instead of minutes, hours or days.

It also became apparent that I needed to learn how to develop relationships at a much higher level with senior administration (the “C-suite”) of both the hospital and the system. While I had interactions with administrators in committee meetings and other settings over the years, I realized that I needed to get a better sense of the breadth of information that was important to them. Pharmacy just wasn’t their world like it was mine.

Connecting on Common Ground

Since professional organizations have always been a big part of my life, I started looking for options to help me in these areas. Many pharmacy organizations, and ASHP in particular, work to develop leaders and leadership skills, but I was looking for a route to connect on common ground with senior leadership. After some searching and a discussion with my friend Mike Sanborn, it didn’t take me long to find the American College of Healthcare Executives (ACHE).

Once I did, I reached out to my senior vice president, a regent and fellow of ACHE, and she happily supported my application for membership. I learned that to achieve fellow status with ACHE, one must be a member of the organization for at least three years and then pass an exam to demonstrate competence. I always like to be in pursuit of the next challenge, so I joined the college. So far, ACHE has provided useful information and set me on a possible path for fellow status.

There have been many conversations about the need for pharmacists to work to find common ground with C-suite leaders. We commonly present and publish information about the impact of pharmacists’ services on clinical decisions, medication safety and the effective operation of a high-performing department. Unfortunately, we often tend to present that information just to each other.  ACHE and its fellowship process is one way to move beyond our comfort zones and demonstrate competence in the health care administration field. I am sure there are others, but I would encourage all pharmacy leaders to identify those elements to advance that common ground with other health care administrators.

The FACHE Credential

The ACHE fellowship designation is the most widely recognized administrative credential in the United States.  The credential requires several steps that are quite different from an ASHP fellowship. An applicant is required to be an ACHE member for a minimum of three years, have a master’s or other postbaccalaureate degree, and have a minimum of five years of health care management experience, which includes management experience as a director of pharmacy.

Once the above prerequisites have been obtained, a prospective fellow must submit three references from current fellows of ACHE and must complete 40 hours of continuing education. Applicants must also participate in at least two community or civic activities.

Finally, applicants must pass the 200-question Board of Governors healthcare management exam, which covers governance and organizational structure, human resources, financial management, healthcare technology and information management, quality and performance improvement, laws and regulations, professionalism and ethical knowledge, general healthcare, management, and business acumen. For more information, go to the ACHE website.

Editor’s Note: Thomas J. Johnson, Pharm.D., MBA, BCPS, FASHP, FCCM, is director of hospital pharmacy at Avera McKennan Hospital and University Health Center in Sioux Falls, S.D., and a member of ASHP’s Board of Directors. Michael D. Sanborn, M.S, FASHP, FACHE, CEO and president of Baylor Medical Center at Carrollton, Tex., contributed to the article.

December 20, 2011

Why I Applied for an ASHP Internship

Jacalyn Jones will graduate from Northeast Ohio Medical University in 2013.

THE VALUE OF AN ASSOCIATION TO A STUDENT goes far beyond membership dues, resources or meetings. It also offers a sense of belonging within the pharmacy profession.

This sense of belonging to something bigger than me is a feeling I have had from the moment I turned in my membership form for the student society at Northeast Ohio Medical University. Throughout the past two years as a member of my student chapter, I took on the roles of professional development chair and secretary. Both positions helped me to advance our organization and allowed me to have a solid grasp on the role of health-system pharmacists at a local level.

That experience whetted my appetite to learn more about what happens at the national association level before beginning my journey as a pharmacist. I applied for the ASHP Summer Internship program hoping to learn what it was like to work in an association environment and learn even more about what a lifelong professional membership has to offer.

ASHP is a Connected Society
I spent 10 weeks at ASHP this past summer learning how to become a better professional through the acquisition of networking, advocacy and communication skills. For years, I heard about what a small world pharmacy is. But it wasn’t until I traveled to Denver for the ASHP 2011 Summer Meeting that I truly understood this concept.

The meeting exposed me to various networking opportunities and showed me what role an association plays in connecting its members and developing new leaders. Another key concept I learned this summer was the importance of the relationships among ASHP’s local, state and national partners. I learned about the vital connection between the state affiliates and their student societies, and how they work together with ASHP to improve the pharmacy profession.

My Take-Home Messages
While at ASHP, I learned how to become an advocate for the profession and for myself. I learned that change can be a slow, deliberative process, and that in order to move our profession forward, it is essential to create inspiring initiatives such as ASHP’s Pharmacy Practice Model Initiative and Pharmacy Technician Initiative.

Every project that I worked on for these initiatives helped to move them forward. I learned to see the value in my research efforts and to take pride in my part in fulfilling a new, improved practice vision.

Finally, I witnessed the sense of passion and commitment that ASHP has for its membership and the amount of effort that the Society’s members, leadership and staff exert to improve pharmacy practice and patient care.

Overall, this experience as the ASHP summer intern helped me to develop myself and discover my strengths and weaknesses. I was able to grow so much in such a short period of time through the people I met, career stories I heard and confidence I have gained.

Due to this experience, I now feel that I have a real role to play within the profession after graduation, and I highly encourage other students to actively participate in their societies and state affiliates as well as with ASHP.

September 23, 2011

Creating an Anticoagulation Service in a Community Pharmacy

From left, Michah Hata, Pharm.D., and Roger S. Klotz, R.Ph., BCNSP, FASCP, FACA, FCPhA

THE MEDICAL LITERATURE is filled with examples of how anticoagulation services managed by pharmacists help reduce the number of anticoagulation-related emergency room visits and hospitalizations. This, in turn, results in significant cost savings1.

Typically, these types of clinics only occur within health systems or medical group practices. But as pharmacy faculty members, I and my colleague, Micah Hata, wondered if this collaborative practice model could be implemented in a community pharmacy.

Overcoming Challenges

So, we worked with a community pharmacist owner in Arcadia, Calif., to add patient care services to his pharmacy. The pharmacy has a private area that can be used as a treatment room to provide patient confidentiality.

We faced a number of major challenges with this project, including:

• Physicians’ resistance to a community pharmacist managing their patients’ warfarin therapy,

• Patient concern about the pharmacists’ capability to manage a therapy that posed significant risk, and

• Payers’ lack of familiarity with community pharmacists’ billing under the major medical plans for services as well as pharmacist-managed medication therapy.

The first task in implementing such a service was to find a licensed physician to medically approve our warfarin management protocol. The second step was to obtain an FDA “Clinical Laboratory Improvement Amendments Waived” testing laboratory certificate so that the pharmacy could officially be recognized as a licensed laboratory. Both tasks were completed by the end of June 2009.

We then faxed a letter along with our physician referral form to the offices of four doctors in our community. The letter detailed the services we would be providing. Within two weeks, the four physicians began to refer patients to our clinic.

Two years later, we have 25 physicians who regularly refer their patients to us. The interesting thing is that we have never marketed to any physicians other than the original four. Therefore, the network of referring physicians has been developed by word-of-mouth among physicians and patients.

A Success Story

Patients have easily accepted pharmacists as providers of direct patient care services, including anticoagulation services. In fact, they have all commented on how much they prefer the pharmacy-based services. We currently have 71 active patients who utilize our services, many of whom have been with us since our debut.

Success in obtaining reimbursement from the patient’s insurance company has been the major challenge. Pharmacists were not listed as approved providers in the original Medicare Act. As a result, we cannot bill Medicare via Palmetto, Medicare’s intermediary claims processor. On the other hand, if the patient has a PPO as either a primary or secondary payer to Medicare, then we can bill the private payer.

One major payer in California initially refused to accept our claims because it had never seen pharmacists bill the major medical plan. Over time, we worked with this payer and responded to every question. We circumvented its refusal to acknowledge pharmacists as providers by starting a group practice, which the payer was willing to accept as a provider in its network.

We were finally informed that we are now listed as a provider in the payer’s network and now receive reimbursement. There are a number of other payers we are billing and from whom we receive reimbursement. Medicare Part B continues to be a problem, and we plan to inform our patients that reimbursement from Medicare is not available.

The best outcome of this new venture is that none of our patients have had problems with adverse events that necessitated a trip to the ER or admission to the hospital as a result of their anticoagulation therapy. In fact, we are now also receiving referrals for the collaborative management of diabetes Type II patients as part of our medication therapy management approach.

It’s clear from our experience that pharmacist-managed direct patient care services can be implemented in a community pharmacy.

By Roger S. Klotz, R.Ph., BCNSP, FASCP, FACA, FCPhA,  and Micah Hata, Pharm.D. Both authors are assistant professors at Western University of Health Sciences, Pomona, Cal.

1 Comparison of “Two Different Models of Anticoagulation Management Services with Usual Medical Care,” Rudd, KM, Dier,  JG; Pharmacotherapy, April 2010; 30(4): 330–338.

June 14, 2011

Care Rounds Improve Pharmacist-Patient Communication

Pharmacists Joy Patterson and Amy Fawcett work with a patient at Foundation Surgical Hospital.

THE PHARMACY DEPARTMENT AT FOUNDATION SURGICAL HOSPITAL in San Antonio is taking our customer service and medication education to the next level. Our hospital specializes in orthopedic, bariatric, neurology, and other elective surgical procedures. The patient care goal of Foundation is to surpass the patient’s expectations in health care.

Though we feel like part of the Foundation family, the pharmacists are contract employees of Comprehensive Pharmacy Services. We aspire to seize every opportunity to practice patient-focused care, integrity, excellence, and servant leadership at Foundation. It is our ambition to expand our visibility and value to the hospital, medical staff, and patients on a daily  basis. One of our latest accomplishments has been the beginning of our Pharmacy Care Rounds service.

Improving Pharmacist-Patient Interaction

Before November 2010, the pharmacist’s participation in patient education opportunities could be described as hit-or-miss. Though the pharmacists, Amy Fawcett, Joy Patterson, and I, assisted the medical staff with drug therapy questions, daily patient contact was missing.

Interaction occasionally occurred when warfarin education or an unusual circumstance prompted a nursing staff member to ask for help from the pharmacy department. REM counseling and pain management assessments are standard services provided by our pharmacists, but because we are a small facility, these patient interactions are somewhat limited.

Foundation Surgical Hospital participates in a patient survey process. This reporting mechanism allows our services and facility to be compared nationally with other hospitals. One of the items on the survey that rated below our expectations (but still above the national average) was communicating with patients about their medications.

Pharmacy Care Rounds

The pharmacists discussed possible solutions, which I then took to Chief Nursing Officer Ken Crouch. We decided to try something new called Pharmacy Care Rounds. The hospital’s administration approved a small financial commitment for printed materials, and the pharmacists rose to the challenge.

The Pharmacy Care Rounds are personal visits by a pharmacist with each inpatient during his or her hospital stay. A pharmacist uses the visit to discuss pain control, disease state medication compliance, new medications, and allergy and side-effect issues.

We have numerous patients who have very little knowledge of their allergies or medications. Lack of well-documented information makes our job of patient safety difficult to manage.

To help, we started distributing the ASHP Foundation’s “My Medication List,” found at www.safemedication.com. This is a great tool in which patients record their medications and medical history in an easy-to-use format that facilitates the transfer of information at doctor visits, outpatient pharmacies, or future hospital admissions.

The patient can also go to the website, download an additional copy of the form, complete it electronically, and save and print multiple copies.

Another handout that we leave with our patients discusses the Institute for Safe Medication Practices’ (ISMP’s) Consumer Med Safety website, which allows patients to receive alert messages about the medications they take. Lastly, the pharmacist leaves a business card, in case the patient thinks of a question after we visit.

Improving Survey Scores

Pharmacy rounds have not only benefited our patients; they have helped improve the reputation of hospital pharmacists. Consistently, our patients say that they did not know that hospitals had pharmacists, and they are thrilled we take the initiative to talk about their concerns.

The hospital’s survey scores rose 10 points in the first quarter following the implementation of these rounds. Links to SafeMedication.com and ISMP’s Consumer Med Safety site have been added to the patient page of the hospital’s website. Next on the pharmacy department’s agenda is expansion of the Pharmacy Care Rounds into the preoperative and outpatient areas.

By Lori P. Houser, R.Ph., pharmacy director of comprehensive pharmacy services, Foundation Surgical Hospital, San Antonio, Tex.

March 28, 2011

Helping Residents Prepare for Emergencies

Managing the chaos of an evolving emergency requires a trained multidisciplinary team.

THERE HAS BEEN A PLANE CRASH NEARBY, a train car containing chlorine gas has just spilled, we need to evacuate the third floor of the hospital within the hour, and a terrorist bomb just exploded downtown.

Luckily, the confluence of these events is unlikely. They are all separate training scenarios in which our hospital has participated to test our emergency response capabilities over the past few years. Pharmacy residents from the Baptist Medical Center Downtown and Wolfson Children’s Hospital in Jacksonville, Fla., have assisted and learned during these drills, adding a unique experience to their training.

The pharmacy residency program is in its fifth year of training post-graduate doctors of pharmacy with two tracks, including a PGY-1 and a PGY-1 with pediatric emphasis. The program provides 12 months of training to residents and includes opportunities to accelerate their professional growth, practice direct patient care, and to learn the art and science of clinical pharmacy practice.

Emergency preparedness and disaster medicine topics are not typical curricula taught in schools or during residency, making this training a unique opportunity.

The residents learn that disaster preparedness involves preparing for and responding to a multitude of low-probability situations that have the potential to disrupt normal day-to-day hospital operations. It may involve something as small and local as a multi-vehicle accident on the interstate or a large-scale event like Hurricane Katrina that potentially affects multiple regions.

The Cycle of Emergency Prep

Preparing and responding is not the only function residents learn about during these drills… they also learn the art of sustaining pharmacy operations as a health system and recovery afterward. Disaster preparedness encompasses the cycle of preparing, responding, sustaining, and recovering.

During training, residents participate in lectures and exercises. At times, our residents participate as healthcare providers during mock mass casualty incidents; at other times, they are paired with senior leaders and administrators to learn the finer points of evaluating how the staff responds to various events.

Some of our more motivated residents even volunteered to be “patients” during an evacuation training scenario. They were strapped to transport “sleds” and safely lowered, multiple times, down the hospital tower stairwell.

Showcasing Pharmacists’ Skills

Placing residents in these roles allows them to gain an appreciation for the amount of work and coordination it takes to respond to various situations and learn the importance of their roles in a disaster situation. It also allows them to network with leaders from other departments and areas across the health system and showcases the strength of pharmacy residents to people who might not ordinarily work directly with a pharmacist.

We find that often the fresh eyes of a young pharmacy resident can provide a unique view, solution, or critique that often leads to improvements during after-action reviews.

All disciplines within the hospital should be involved in drills, training, and planning. An article in The Journal of Rescue and Disaster Medicine states, “…hospital disaster preparedness can only be achieved with active participation of all key medical service providers within a multidisciplinary team.” The importance of training pharmacists and residents in this field is important as “…pharmaceutical services represent one of the most important and yet under-recognized services in mass casualty care.”1

The ICU pharmacist and nursing team follow hospital protocols during a mock bomb threat.

The largest value in participating in drills and training within the hospital is the recognition of services that everyone is able to provide and the reinforcement of relationships between the various components that make up our system.

Pharmacists have been involved with disaster medicine and provided expertise on the ground in situations such as the earthquake in Haiti, after Hurricane Katrina, and post 9-11. During the 2009 H1N1 influenza outbreak pharmacists assisted not only with vaccine procurement and distribution, but also with education and administration. The pharmacy residents at Wolfson and Baptist Downtown have learned that pharmacists can play a vital role during times of stress and they stand ready to assist when the next situation arises.

By Matthew J. Geraci, Pharm.D., EOD, clinical pharmacist in emergency medicine, Baptist Medical Center Downtown, Jacksonville, Fla.

1. Hospital Disaster Preparedness in the United States: New Issues, New Challenges. Journal of Rescue and Disaster Medicine. 2005: 5(2).

 

December 26, 2010

Establishing Pharmacotherapy Services in a Primary Care Clinic

Filed under: What Worked for Me — Tags: , , — admin @ 11:15 am

Melissa Max, Pharm.D., far right, counsels a patient while a Harding University pharmacy student observes.

How did you get involved with the university’s partnership with ARcare?
It’s part of my responsibilities as a faculty member. The partnership was already in place when I joined the Harding staff in October of 2008. The idea was to put a faculty member in the clinic, and I started by going to the clinic one day a week to conduct patient reviews. It all began very simply. I developed a rapport with Bonnie Dillard, APN, the nurse practitioner involved with the clinic, and she was open to many of the things I suggested.  If I saw anything potentially problematic, like drug interactions or dosing issues, I wrote my concerns down and brought them to her. I didn’t even start with charting in an electronic medical record.

Why did you decide to focus on cardiovascular care?
We wanted to reach the greatest number of patients possible. Based on the number of patients who weren’t at goal for blood pressure, lipid management, and diabetes management, we determined the need for a cardiovascular focus.

What kind of criteria did you develop for providing care?
We wanted to start with high-risk patients, so they had to have at least two chronic disease states and be taking at least five medications. Most of them were taking between seven and nine medications. The program stresses evidence-based medicine, and I use evidence-based guidelines for any recommendations I make. We chose LDL cholesterol and blood pressure for our outcome measures.

What are the nuts and bolts of the program?
The program focuses on identifying potential adverse drug events and addressing concerns early, before a problem develops. Once we identify the patients at risk, we send them a letter of introduction explaining that we want to offer them pharmacy services. We follow established standards of care. For example, if it is necessary to add a medication for blood pressure or a statin for lipids, we follow up to make sure the patient got the appropriate lab work.

%%sidebar%%How did you develop a rapport with the ARcare staff?
I focused on collaboration, and how my work is not a challenge to theirs but an enhancement. For instance, Bonnie was seeing 30 patients a day. By concentrating on cardiovascular care and seeing fewer patients, I could focus and use my training. It takes a secure person to let someone come in and look over his or her shoulder, and when we started seeing improvements in patients, I explained how those markers show the value of working together. Bonnie’s support was important. I wouldn’t have been able to do any of this without getting her buy-in.

Do you have any advice for pharmacists who would like to partner with clinics?
If you are a faculty member or staff pharmacist, get the support of your leadership. Try to partner with a clinic that is focused on patient safety. Since health care is moving toward pay-for-performance, more clinics will be concentrating on safety and outcomes. Also, be strong clinically. Stay up-to-date on treatment guidelines, so you can bring value to the patients. And finally, remember to be tactful. As pharmacists, we are very focused on the drugs. But it’s important to also work on the total patient presentation. If you are working with other providers who know their patients very well, they can help you by giving you information and background before you meet with a patient. Be ready to put the time in to develop relationships with both patients and providers.

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