CASE STUDY
Pharmacy Practice Model Initiative
ar
CASE STUDY
Layar
Moving the Pharmacy Practice Model Initiative forward within a state affiliate Ryan J. Bickel, Curtis D. Collins, Richard L. Lucarotti, James G. Stevenson, Kathleen Pawlicki, Terry J. Baumann, and Denise M. Pratt
T
he goal of the ASHP Pharmacy Practice Model Initiative (PPMI) is to significantly advance the health and well-being of patients in health systems by developing and disseminating optimal pharmacy practice models that are based on the effective use of pharmacists as direct patient care providers.
Problem After the Pharmacy Practice Model Summit in November 2010, the board of directors of the Michigan Society of Health-System Pharmacists (MSHP) began to strategize ways to help health-system pharmacists in Michigan achieve the vision and concepts envisioned by the PPMI.1,2 The ultimate goal was to develop a process for acting on recommendations developed by the PPMI to advance the practice of healthsystem pharmacy in Michigan. Analysis and resolution Task force development and conference preparation. The MSHP
Purpose. Efforts to advance the ASHP Pharmacy Practice Model Initiative (PPMI) in the Michigan Society of Health-System Pharmacists (MSHP) are described. Summary. After the Pharmacy Practice Model Summit in November 2010, the board of directors of MSHP began to strategize ways to help health-system pharmacists in Michigan achieve the vision and concepts envisioned by the PPMI. The ultimate goal was to develop a process for acting on recommendations developed by the PPMI to advance the practice of healthsystem pharmacy in Michigan. A task force was formed and reviewed the 147 national recommendations from the ASHP Pharmacy Practice Model Summit and grouped them into related areas of focus. Six focus areas were identified: acute care, ambulatory care, education and training, organizational affairs and leadership, pharmacy technicians, and technology and informa-
board of directors formed a planning task force to advance efforts and implement recommendations from the PPMI in the state of Michigan. This task force comprised two MSHP members from Michigan
Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of
tion systems. A PPMI Michigan conference was arranged in which focus groups would assess these six areas. Each focus group was limited to six or seven participants, with a member of the task force serving as the facilitator for the group. Individual focus groups then formulated recommendations MSHP could develop into actionable strategies to address the key issues identified during the morning session. A total of 56 recommendations were submitted by the focus groups for consideration by all conference participants. Over 80% of the recommendations were deemed to be high impact/high feasibility. Conclusion. A process for acting on recommendations of the ASHP PPMI to advance the practice of health-system pharmacy within the state of Michigan was developed. Am J Health-Syst Pharm. 2014; 71:167985
who attended the ASHP Pharmacy Practice Model Summit; the current president, immediate past-president, president-elect, and executive director of MSHP; a member of the MSHP board of directors; and the
Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI. Address correspondence to Dr. Pratt ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1001-1679. DOI 10.2146/ajhp140056
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staff liaison from the Michigan Pharmacists Association (MPA). The task force initially met in person in February 2011 to determine the goals and vision for implementation strategies within the state. A PPMI of Michigan (PPMI2) conference was ultimately proposed by the task force. The goals of the PPMI2 conference were to (1) provide a foundation for MSHP to develop strategies to disseminate the ASHP PPMI recommendations to Michigan health-system pharmacies, (2) develop practical, operational tools to assist health systems in implementing practice model changes, and (3) facilitate changes necessary to allow for practice model change with outside constituencies and regulatory bodies. On approval of this plan, the MSHP board of directors allotted $6000 to host this conference. The decision was made to use the MPA office building, which allowed meeting space to host 50 participants with no facility cost and helped determine the number of participants. The remainder of the work of the task force was carried out by conference calls and assigned tasks until the time of the conference. Most of the preparation time spent by task force members involved contacting and encouraging pharmacy department directors to complete the PPMI selfassessment tool. Conference details such as mailings, reservations, and facility setup were managed by MPA staff members without whom this conference would not have been able to occur. The task force reviewed the 147 national recommendations from the ASHP Pharmacy Practice Model Summit and grouped them into related areas of focus. Six focus areas were identified: acute care, ambulatory care, education and training, organizational affairs and leadership, pharmacy technicians, and technology and information systems. Pharmacy leaders from Michigan were invited to participate in the summit. 1680
In order to determine a group of leader participants, the task force provided names of candidates who they felt represented pharmacy leaders from varying practice sites, with diverse expertise and roles within Michigan health systems. From this list of candidates the task force developed an invitation list with the goal of obtaining persons throughout the state that represented various sized health systems, the different regions of the state, varying years of practice experience, and different practice settings. Upon accepting the invitation, candidates were placed in one of the six focus groups. Each focus group was limited to six or seven participants, with a member of the task force serving as the facilitator for the group. Preparatory information, which included a copy of the ASHP executive summary of the PPMI and topic-specific readings pertaining to the assigned focus group, was provided to each invitee for review before the summit. Task force members enlisted the assistance of William Zellmer, former deputy executive vice president of ASHP, to deliver the keynote address and assist with event planning, facilitator preparation, and review of conference proceedings and results. To prepare for the PPMI2 conference, the task force characterized baseline pharmacy practice model status in Michigan through the development and distribution of two surveys. Permission was obtained from ASHP to use the newly created, Web-based PPMI hospital self-assessment tool.3 A link to this self-assessment tool was sent to the pharmacy director at each Michigan hospital. Approximately one third of the directors completed the selfassessment tool. A customized survey was created by the MSHP PPMI2 task force and sent to each invitee before the conference to obtain information not captured in the national survey. This survey focused on the use of pharmacy technicians, education
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and training, and pharmacy technology. Of the 50 invitees, 42 completed the survey before the conference. A copy of this survey and the results are located on ASHP Connect (http:// connect.ashp.org) under the MSHP state affiliate community. Experience at the conference. The PPMI2 conference took place in September 2011 in Lansing, Michigan. The 50 invitees included pharmacy students, residents, technicians, and pharmacists from all aspects of health-system pharmacy, including informatics, ambulatory care, inpatient clinical specialists, generalists, and management. The day opened with a keynote presentation describing national trends affecting health-system pharmacists. After the opening address, attendees reviewed results from the two surveys to gain a better perspective on current pharmacy practices within Michigan. Participants then broke out into their individual groups to identify major issues affecting their focus area. The critical issues discussed in each focus group are described below. Acute care. Discussions centered on inpatient staffing and the pharmacy services that should be provided or held as an expectation for achievement. Three critical issues were identified: (1) ensuring competency and training in pharmacy staff, (2) effectively integrating all pharmacy personnel into a new model, and (3) determining how to identify and prioritize services in the new model. Ambulatory care. The issues identified surrounded pharmacy’s evolving role in the ambulatory care setting included the following: How can regulators (e.g., legislators, accreditation organizations, payers) be convinced to allow expansion of collaborative practice and prescribing? How can we ensure that clinical pharmacy services are standardized and always present and payable in every accountable care organization model in Michigan? How are inno-
CASE STUDY
vative clinical ambulatory practice models adopted and expanded outside the traditional setting (e.g., rural areas, retail, independent businesses)? Education and training. The recommendations developed and brought forth from this focus group centered on MSHP strengthening its working relationship with the state’s three colleges of pharmacy and the state’s health-system pharmacies. The three critical issues necessary to strengthen education and training were (1) increasing the number of sites and positions for residency training within the state, (2) increasing the number of rotations and sites for students within the state, and (3) developing strategies to integrate students or residents into active pharmacy practice to advance the practice model. Organizational affairs and leadership. Two critical issues relating to leadership in MSHP and within the practice of pharmacy were identified: (1) demonstrating and communicating our unique value in patient care to other healthcare providers, payers, and patients, and (2) ensuring our work force is competent to practice in the new practice model. Pharmacy technicians. The focus group on pharmacy technicians identified five critical issues: (1) overcoming real or perceived barriers in advancing the certified pharmacy technician (CPhT) role, (2) defining, measuring, and justifying the role of the CPhT in practice within the state, (3) ensuring that health systems have career paths or tracks for CPhTs that encourage full participation in the healthcare team, (4) increasing access to ASHP-accredited technician training programs, and (5) achieving a legal and regulatory environment that supports development of a pharmacy technician work force. Technology and information systems. This focus group’s exploration of ways to advance the pharmacy practice model through more-effective use of
Pharmacy Practice Model Initiative
technology led to the identification of the following four critical issues: (1) using evidence-based medicine to design effective decision-support tools, (2) utilizing technology to improve drug distribution quality and accuracy and as a means to reduce the pharmacist’s time in the dispensing process, allowing more time for direct patient care activities, (3) creating tools that can be implemented to triage, prioritize, and assign potential medication-related problems for resolution by pharmacists, and (4) improving safety and efficiency of order review and verification with the use of technology. Evaluating focus groups’ recommendations. Individual focus groups then formulated recommendations MSHP could develop into actionable strategies to address the key issues identified during the morning session. The focus groups reconvened and presented their recommendations to all meeting attendees. Each participant was given an electronic voting device to assess the feasibility and impact of each recommendation presented. Participants judged each recommendation as having (1) low impact/low feasibility, (2) high impact/low feasibility, (3) low impact/ high feasibility, or (4) high impact/ high feasibility. Participants could also choose to have no opinion about the impact or feasibility of a recommendation. Recommendations from the six focus groups are listed in Table 1. A total of 56 recommendations were submitted by the focus groups for consideration by all conference participants. Over 80% of the recommendations were deemed to be high impact/high feasibility. Discussion After the conference, many of the high-impact/high-feasibility recommendations were incorporated into the 2012, 2013, and 2014 MSHP committee charges. As part of the yearly MSHP planning process, the
president-elect selected the recommendations from the PPMI2 list to be incorporated into the committee charges for his or her presidential term with board review, revision, and approval. The committees developed action plans for the merging of the recommendations into activities and goals of MSHP. Some of the recommendations, particularly those related to pharmacy technology and informatics, did not align with a current MSHP committee structure. To solve this problem, the MSHP board of directors created a pharmacy technology and informatics task force to develop an action plan related to these recommendations. We encountered some challenges during the planning process. First, we did not have a current list of pharmacy contacts and healthcare facilities throughout Michigan. This required the development of an accurate and up-to-date list of current health-system pharmacy directors and their contact information before dissemination of the ASHP hospital self-assessment tool. The maintenance of an accurate list is now an ongoing charge for the MSHP membership committee and provides a valuable resource to the society when information needs to be disseminated to all health-system pharmacies. In addition, the selfassessment response rates were initially low. The planning committee increased response rates by personally contacting pharmacy directors to encourage participation. The conversion of the recommendations into committee responsibilities was also challenging during the first year after the conference. We found that the charges presented to the committees during the year were initially too ambiguous in scope, and the committees struggled to identify enough direction or taskspecific responsibilities, which would provide measurable outcomes. One such example was a charge asking the committee to create, over the
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Table 1.
PPMI Recommendations Developed by Focus Groups2,a
Recommendations in Targeted Areas Acute care How do we ensure staff competency and training? MSHP develops intense continuing-education programs leading to certification for pharmacists with periodic recertification (e.g., anticoagulation management, pharmacokinetics, pain management) (n = 45) MSHP advocates for PGY1 training or equivalent experience for hospital pharmacist positions and PGY2 and/or board certification for specialized positions or for positions caring for complex patients (n = 46) MSHP advocates for ASHP accreditation of technician training programs in the state. MSHP also advocates that the state requires technician certification and registration (n = 44) MSHP advocates for the requirement of greater practical training hours for pharmacist licensure (n = 46) How do we effectively integrate all pharmacy personnel into a new model? MSHP develops a toolkit/webinars/speakers bureau to explain the PPMI to pharmacy staff to ease apprehension (n = 46) MSHP encourages pharmacy leaders to develop career ladders (n = 45) MSHP highlights innovative practice models in the state (n = 46) How do we identify and prioritize services in the new model? Pharmacy leaders should advocate for minimum pharmacy services to include drug distribution, pharmacokinetics, anticoagulation management, and antimicrobial stewardship for all practice settings (n = 46) Pharmacy leaders use data from order volumes, survey of patients, nurses, physicians, and staff in conjunction with staff consensus to develop model structure and services (n = 46) MSHP advocates for medication-related national quality indicators for hospitals and also educate on how pharmacists can obtain those goals (n = 46) MSHP grant or award for PPMI best practices (n = 46) Pharmacy leaders should align department goals with those of hospital leadership (n = 46) Ambulatory care How can we convince regulators (legislators, accreditation organizations, payers) to allow expansion of collaborative practice and prescribing? MSHP to review collaborative practice agreements in other states and analyze changes in Michigan laws to facilitate such agreements (n = 46) MPA to lobby for change in Public Health Code verbiage to include pharmacists as prescribers (n = 47) MSHP to investigate barriers for payers to pay when collaborative agreements are in place (n = 47) How do we assure pharmacy clinical services are standard (means pharmacist clinical services are always present) and payable in every ACO model in Michigan? MSHP identifies who makes decisions regarding requirements of ACO and disseminates to members (n = 47) MSHP to investigate mechanisms at the regulatory level—requirements for clinical pharmacy services including ambulatory and nontraditional in all ACOs (n = 46) MSHP to identify various return-on-investment models for pharmacy services in ACOs separate from drug product/dispensing (including dissemination to members) (n = 44)
Highest Impact and Feasibility
No. (%) Respondents in Agreement
HI-HF
21 (46.7)
HI-LF
27 (58.7)
HI-HF
32 (72.7)
LI-LF
20 (43.5)
HI-HF HI-HF HI-HF
30 (65.2) 24 (53.3) 23 (50.0)
HI-HF
27 (58.7)
HI-HF
19 (41.3)
HI-HF LI-HF
25 (54.4) 24 (52.2)
HI-HF
33 (71.7)
HI-HF
29 (63.0)
HI-HF
23 (48.9)
HI-HF
28 (59.6)
HI-HF
26 (55.3)
HI-HF
22 (47.8)
HI-HF
24 (54.6)
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Table 1 (continued) Highest Impact and Feasibility
Recommendations in Targeted Areas How do we adopt and expand innovative clinical ambulatory practice models outside the traditional setting (e.g., rural areas, retail, independent businesses)? MSHP to work with payers to establish standardized clinical pharmacy services that would be paid for at the individual pharmacist level and disseminate the information (n = 46) Create a new section in MPA for ambulatory care, infusion, and home care which will include establishing standard ambulatory clinical practice programming at the annual MPA meeting (n = 47) Develop new clinical sites by (1) collaborating with colleges of pharmacy, current residency programs, and the Michigan Colleges of Pharmacy Education Panel to utilize trainees to develop ambulatory clinical service business plan, (2) incorporating training on how to duplicate ambulatory services in different practice settings, and (3) developing electronic toolkits and clinical learning collaborative (n = 47) Education How do we increase the number of sites/positions for residency training? MSHP should provide a resource toolkit to start a residency (basic startup, value, address barriers, preceptor training, provision of an advisor for startup) (n = 45) MSHP should identify potential sites for residency programs (n = 46) Colleges of pharmacy should work with sites to determine ways they could support residency program development (n = 45) Site should create models of training beyond one-to-one training for residents and students (e.g., medical model) (n = 45) MSHP should work with sites to consider yearly expansion (increased number of positions) of their current residency programs (n = 46) How do we increase the number of rotations/sites for students? Colleges of pharmacy and MSHP should promote to sites the need and benefits to provide experiential education (n = 45) Colleges of pharmacy should work with sites to determine services that students could participate in to increase student capacity and increase service provision (n = 45) MSHP should encourage directors of pharmacy to develop department mission statements that include a culture of providing education as part of practice (n = 46) How can we integrate students or residents into active pharmacy practice to advance the practice model? Colleges of pharmacy and sites should develop a listing of skill/competencies for students at each level of training (n = 46) MSHP should work with colleges of pharmacy to develop a listing of best practices that demonstrate integration of students into practice (n = 45) Leadership How do we demonstrate and communicate our unique value in patient care? MSHP should establish a list of consistent metrics to demonstrate value of direct patient care activities (n = 46) MSHP should design a communication tool/campaign to send a consistent message to our stakeholders (n = 46) MSHP should strongly endorse pharmacists as physician extenders (n = 45) MSHP should develop a speakers bureau to train the trainer on PPMI core elements (n = 45)
No. (%) Respondents in Agreement
HI-LF
26 (56.5)
HI-HF
20 (42.6)
HI-HF
19 (40.4)
HI-HF HI-HF
35 (77.8) 23 (50)
HI-HF
27 (60)
HI-HF
28 (62.2)
HI-HF
20 (43.5)
HI-HF
22 (48.9)
HI-HF
34 (75.6)
HI-HF
20 (43.5)
HI-HF
28 (60.9)
HI-HF
38 (84.4)
HI-HF
31 (67.4)
HI-HF HI-HF
28 (60.9) 27 (60.0)
HI-HF
26 (57.8)
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Table 1 (continued)
Recommendations in Targeted Areas How do we ensure our work force is competent to practice in the new practice model? MSHP should utilize members to advocate for certification and licensure of pharmacy technicians (n = 45) MSHP should develop a tool for directors of pharmacy to assess staff and bring them up to date on the PPMI (n = 46) MSHP should support development of a competency test to assure that pharmacists’ skills match the new practice model standards (n = 46) Technicians How do we overcome real or perceived barriers in advancing the CPhT role? MSHP should work with the MSPT to promote a “changing perceptions” campaign to promote innovative technician practices (n = 46) MSHP should charge the publications committee with spotlighting innovative practices in the MSHP Monitor (n = 45) MSHP should charge the awards committee to sponsor an award for the most innovative technician practice (n = 45) How do we define, measure, and justify the role of the CPhT in practice? MSHP should develop a white paper in conjunction with PTCB on technician practice detailing studies that have been done on effects of technician practice on cost, quality, safety, and customer satisfaction (n = 46) MSHP should charge the education committee and MSPT with developing an innovative technician practice presentation for the annual meeting and various other venues (n = 43) How do we ensure that hospitals and health systems have career paths or tracks for CPhTs that encourage full participation in the healthcare team? MSHP should develop a certification page within the content of PPMI2 page to contain a toolbox with job descriptions, career ladders, and retention programs (n = 45) MSHP should communicate to directors of pharmacy where these materials are located and include examples of team participation such as safety huddles and committee participation (n = 45) How do we increase access to ASHP-accredited technician training programs? MSHP and MSPT should provide help to existing technician training programs to gain and maintain ASHP accreditation, work with existing programs for online access and Web-enabled training, hire from only accredited programs, and post link to ASHP website of accredited programs (n = 45) How do we achieve legal/regulatory environment that supports development of a pharmacy technician work force that will enhance optimal pharmacy practice model? MSHP and MSPT should charge MPA to support legislation or Board of Pharmacy rules promulgation requiring graduation from an accredited program and passing the PTCB examination and licensure of technicians (n = 45) Technology How do we use evidence-based medicine to design effective decision-support tools? MSHP should advocate pharmacist involvement in design and content of order sets (n = 47) MSHP should develop a task force to define a consensus for best practice around clinical decision-support alerts (n = 47)
Highest Impact and Feasibility
No. (%) Respondents in Agreement
HI-HF
32 (71.1)
HI-HF
25 (54.4)
LI-HF, HI-HF
13 (28.3) for both
LI-HF
23 (50.0)
LI-HF
31 (68.9)
LI-HF
29 (64.4)
HI-HF
26 (56.5)
HI-HF
21 (48.8)
HI-HF
27 (60.0)
LI-HF
25 (55.6)
HI-HF
26 (57.8)
HI-HF
29 (64.4)
HI-HF
35 (74.5)
HI-HF
37 (78.7)
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Table 1 (continued)
Recommendations in Targeted Areas How do we use information technology to improve drug distribution quality as a means to free pharmacist time (maximize bar technology)? MSHP should advocate for research to validate automated drug product selection technologies (n = 46) MSHP should advocate for the use of validated technologies that free pharmacist time to pursue patient medication management issues (n = 46) MSHP should advocate for development of regulations that support the use of validated technologies throughout the drug distribution process (n = 46) How can we create tools that can be implemented to triage/prioritize/assign potential medication-related problems? MSHP should participate in the validation of software/tools developed as part of ASHP PPMI (n = 45) How can we improve safety and efficiency of order review/verification with use of technology? MSHP should develop practice guidelines defining pharmacist expectations as part of order review and verification while incorporating the full potential of technology (n = 46) MSHP should advocate for a change in legal regulations that mandate pharmacists to review all medication orders (n = 46) MSHP should advocate for research to show which segments of medication order review can be automated while providing the same level of or greater safety than pharmacist review (n = 46)
Highest Impact and Feasibility
No. (%) Respondents in Agreement
HI-HF
29 (63.0)
HI-HF
34 (73.9)
HI-HF
30 (65.2)
HI-HF
36 (80.0)
HI-HF
33 (71.7)
HI-LF
22 (47.8)
HI-HF
32 (69.6)
PPMI = Pharmacy Practice Model Initiative, HI = high impact, HF = high feasibility, LF = low feasibility, LI = low impact, MSHP = Michigan Society of Health-System Pharmacists, PGY1 = postgraduate year 1, PGY2 = postgraduate year 2, MPA = Michigan Pharmacists Association, ACO = accountable care organization, CPhT = certified pharmacy technician, MSPT = Michigan Society of Pharmacy Technicians, PTCB = Pharmacy Technician Certification Board. a
next five years, a strategy to highlight advances that health systems in Michigan have made with respect to the PPMI and PPMI2 initiatives. Subsequently, MSHP annual goals were developed with more-specific outcomes defined, such as developing a listing of minimal pharmacy services to be provided, to serve as a guide for PPMI progress. It was recognized by MSHP leadership that many of the recommendations would take several years to complete. To ensure that MSHP maintains its focus on the PPMI2 recommendations, the PPMI2 planning task force transitioned into the strategic planning council. This council monitors progress toward achieving the recommendations set forth by the PPMI2 conference. The council provides guidance to the MSHP board in regard to the strategic plan and continuity of the overall mis-
sion and goals of MSHP. Use of the ASHP hospital self-assessment tool provided us with a pharmacy practice model snapshot within Michigan before the PPMI2 conference. Moving forward, we plan to use the self-assessment tool to evaluate the impact of the conference and MSHP initiatives and the progress toward achieving PPMI goals. Recommendations developed during the PPMI 2 conference are ambitious goals, which will likely take time to implement and achieve. Utilizing the talents and teamwork of MSHP members, MSHP believes it is moving in a direction that will help provide assistance to all healthsystem pharmacies across Michigan. This support will allow the transformation of their practice into an optimal model so they are consistently providing safe, effective, efficient, accountable, and evidence-based care
for all patients in health systems. To further our vision for health-system pharmacy practice, MSHP planned a similar conference for September 2014 to focus on the ambulatory care environment, transitions of care, and continuity of care utilizing information from the ASHP Ambulatory Care Conference and Summit. Conclusion A process for acting on recommendations of the ASHP PPMI to advance the practice of healthsystem pharmacy within the state of Michigan was developed. References 1. Executive summary. Am J Health-Syst Pharm. 2011; 68:1079-85. 2. The consensus of the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1148-52. 3. American Society of Health-System Pharmacists. PPMI hospital self-assessment tool. http://ppmiassessment.org/ (accessed 2013 Aug 20).
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CASE STUDY
Layar
Moving the Pharmacy Practice Model Initiative forward within a state affiliate Ryan J. Bickel, Curtis D. Collins, Richard L. Lucarotti, James G. Stevenson, Kathleen Pawlicki, Terry J. Baumann, and Denise M. Pratt
T
he goal of the ASHP Pharmacy Practice Model Initiative (PPMI) is to significantly advance the health and well-being of patients in health systems by developing and disseminating optimal pharmacy practice models that are based on the effective use of pharmacists as direct patient care providers.
Problem After the Pharmacy Practice Model Summit in November 2010, the board of directors of the Michigan Society of Health-System Pharmacists (MSHP) began to strategize ways to help health-system pharmacists in Michigan achieve the vision and concepts envisioned by the PPMI.1,2 The ultimate goal was to develop a process for acting on recommendations developed by the PPMI to advance the practice of healthsystem pharmacy in Michigan. Analysis and resolution Task force development and conference preparation. The MSHP
Purpose. Efforts to advance the ASHP Pharmacy Practice Model Initiative (PPMI) in the Michigan Society of Health-System Pharmacists (MSHP) are described. Summary. After the Pharmacy Practice Model Summit in November 2010, the board of directors of MSHP began to strategize ways to help health-system pharmacists in Michigan achieve the vision and concepts envisioned by the PPMI. The ultimate goal was to develop a process for acting on recommendations developed by the PPMI to advance the practice of healthsystem pharmacy in Michigan. A task force was formed and reviewed the 147 national recommendations from the ASHP Pharmacy Practice Model Summit and grouped them into related areas of focus. Six focus areas were identified: acute care, ambulatory care, education and training, organizational affairs and leadership, pharmacy technicians, and technology and informa-
board of directors formed a planning task force to advance efforts and implement recommendations from the PPMI in the state of Michigan. This task force comprised two MSHP members from Michigan
Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of
tion systems. A PPMI Michigan conference was arranged in which focus groups would assess these six areas. Each focus group was limited to six or seven participants, with a member of the task force serving as the facilitator for the group. Individual focus groups then formulated recommendations MSHP could develop into actionable strategies to address the key issues identified during the morning session. A total of 56 recommendations were submitted by the focus groups for consideration by all conference participants. Over 80% of the recommendations were deemed to be high impact/high feasibility. Conclusion. A process for acting on recommendations of the ASHP PPMI to advance the practice of health-system pharmacy within the state of Michigan was developed. Am J Health-Syst Pharm. 2014; 71:167985
who attended the ASHP Pharmacy Practice Model Summit; the current president, immediate past-president, president-elect, and executive director of MSHP; a member of the MSHP board of directors; and the
Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI. Address correspondence to Dr. Pratt ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1001-1679. DOI 10.2146/ajhp140056
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staff liaison from the Michigan Pharmacists Association (MPA). The task force initially met in person in February 2011 to determine the goals and vision for implementation strategies within the state. A PPMI of Michigan (PPMI2) conference was ultimately proposed by the task force. The goals of the PPMI2 conference were to (1) provide a foundation for MSHP to develop strategies to disseminate the ASHP PPMI recommendations to Michigan health-system pharmacies, (2) develop practical, operational tools to assist health systems in implementing practice model changes, and (3) facilitate changes necessary to allow for practice model change with outside constituencies and regulatory bodies. On approval of this plan, the MSHP board of directors allotted $6000 to host this conference. The decision was made to use the MPA office building, which allowed meeting space to host 50 participants with no facility cost and helped determine the number of participants. The remainder of the work of the task force was carried out by conference calls and assigned tasks until the time of the conference. Most of the preparation time spent by task force members involved contacting and encouraging pharmacy department directors to complete the PPMI selfassessment tool. Conference details such as mailings, reservations, and facility setup were managed by MPA staff members without whom this conference would not have been able to occur. The task force reviewed the 147 national recommendations from the ASHP Pharmacy Practice Model Summit and grouped them into related areas of focus. Six focus areas were identified: acute care, ambulatory care, education and training, organizational affairs and leadership, pharmacy technicians, and technology and information systems. Pharmacy leaders from Michigan were invited to participate in the summit. 1680
In order to determine a group of leader participants, the task force provided names of candidates who they felt represented pharmacy leaders from varying practice sites, with diverse expertise and roles within Michigan health systems. From this list of candidates the task force developed an invitation list with the goal of obtaining persons throughout the state that represented various sized health systems, the different regions of the state, varying years of practice experience, and different practice settings. Upon accepting the invitation, candidates were placed in one of the six focus groups. Each focus group was limited to six or seven participants, with a member of the task force serving as the facilitator for the group. Preparatory information, which included a copy of the ASHP executive summary of the PPMI and topic-specific readings pertaining to the assigned focus group, was provided to each invitee for review before the summit. Task force members enlisted the assistance of William Zellmer, former deputy executive vice president of ASHP, to deliver the keynote address and assist with event planning, facilitator preparation, and review of conference proceedings and results. To prepare for the PPMI2 conference, the task force characterized baseline pharmacy practice model status in Michigan through the development and distribution of two surveys. Permission was obtained from ASHP to use the newly created, Web-based PPMI hospital self-assessment tool.3 A link to this self-assessment tool was sent to the pharmacy director at each Michigan hospital. Approximately one third of the directors completed the selfassessment tool. A customized survey was created by the MSHP PPMI2 task force and sent to each invitee before the conference to obtain information not captured in the national survey. This survey focused on the use of pharmacy technicians, education
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and training, and pharmacy technology. Of the 50 invitees, 42 completed the survey before the conference. A copy of this survey and the results are located on ASHP Connect (http:// connect.ashp.org) under the MSHP state affiliate community. Experience at the conference. The PPMI2 conference took place in September 2011 in Lansing, Michigan. The 50 invitees included pharmacy students, residents, technicians, and pharmacists from all aspects of health-system pharmacy, including informatics, ambulatory care, inpatient clinical specialists, generalists, and management. The day opened with a keynote presentation describing national trends affecting health-system pharmacists. After the opening address, attendees reviewed results from the two surveys to gain a better perspective on current pharmacy practices within Michigan. Participants then broke out into their individual groups to identify major issues affecting their focus area. The critical issues discussed in each focus group are described below. Acute care. Discussions centered on inpatient staffing and the pharmacy services that should be provided or held as an expectation for achievement. Three critical issues were identified: (1) ensuring competency and training in pharmacy staff, (2) effectively integrating all pharmacy personnel into a new model, and (3) determining how to identify and prioritize services in the new model. Ambulatory care. The issues identified surrounded pharmacy’s evolving role in the ambulatory care setting included the following: How can regulators (e.g., legislators, accreditation organizations, payers) be convinced to allow expansion of collaborative practice and prescribing? How can we ensure that clinical pharmacy services are standardized and always present and payable in every accountable care organization model in Michigan? How are inno-
CASE STUDY
vative clinical ambulatory practice models adopted and expanded outside the traditional setting (e.g., rural areas, retail, independent businesses)? Education and training. The recommendations developed and brought forth from this focus group centered on MSHP strengthening its working relationship with the state’s three colleges of pharmacy and the state’s health-system pharmacies. The three critical issues necessary to strengthen education and training were (1) increasing the number of sites and positions for residency training within the state, (2) increasing the number of rotations and sites for students within the state, and (3) developing strategies to integrate students or residents into active pharmacy practice to advance the practice model. Organizational affairs and leadership. Two critical issues relating to leadership in MSHP and within the practice of pharmacy were identified: (1) demonstrating and communicating our unique value in patient care to other healthcare providers, payers, and patients, and (2) ensuring our work force is competent to practice in the new practice model. Pharmacy technicians. The focus group on pharmacy technicians identified five critical issues: (1) overcoming real or perceived barriers in advancing the certified pharmacy technician (CPhT) role, (2) defining, measuring, and justifying the role of the CPhT in practice within the state, (3) ensuring that health systems have career paths or tracks for CPhTs that encourage full participation in the healthcare team, (4) increasing access to ASHP-accredited technician training programs, and (5) achieving a legal and regulatory environment that supports development of a pharmacy technician work force. Technology and information systems. This focus group’s exploration of ways to advance the pharmacy practice model through more-effective use of
Pharmacy Practice Model Initiative
technology led to the identification of the following four critical issues: (1) using evidence-based medicine to design effective decision-support tools, (2) utilizing technology to improve drug distribution quality and accuracy and as a means to reduce the pharmacist’s time in the dispensing process, allowing more time for direct patient care activities, (3) creating tools that can be implemented to triage, prioritize, and assign potential medication-related problems for resolution by pharmacists, and (4) improving safety and efficiency of order review and verification with the use of technology. Evaluating focus groups’ recommendations. Individual focus groups then formulated recommendations MSHP could develop into actionable strategies to address the key issues identified during the morning session. The focus groups reconvened and presented their recommendations to all meeting attendees. Each participant was given an electronic voting device to assess the feasibility and impact of each recommendation presented. Participants judged each recommendation as having (1) low impact/low feasibility, (2) high impact/low feasibility, (3) low impact/ high feasibility, or (4) high impact/ high feasibility. Participants could also choose to have no opinion about the impact or feasibility of a recommendation. Recommendations from the six focus groups are listed in Table 1. A total of 56 recommendations were submitted by the focus groups for consideration by all conference participants. Over 80% of the recommendations were deemed to be high impact/high feasibility. Discussion After the conference, many of the high-impact/high-feasibility recommendations were incorporated into the 2012, 2013, and 2014 MSHP committee charges. As part of the yearly MSHP planning process, the
president-elect selected the recommendations from the PPMI2 list to be incorporated into the committee charges for his or her presidential term with board review, revision, and approval. The committees developed action plans for the merging of the recommendations into activities and goals of MSHP. Some of the recommendations, particularly those related to pharmacy technology and informatics, did not align with a current MSHP committee structure. To solve this problem, the MSHP board of directors created a pharmacy technology and informatics task force to develop an action plan related to these recommendations. We encountered some challenges during the planning process. First, we did not have a current list of pharmacy contacts and healthcare facilities throughout Michigan. This required the development of an accurate and up-to-date list of current health-system pharmacy directors and their contact information before dissemination of the ASHP hospital self-assessment tool. The maintenance of an accurate list is now an ongoing charge for the MSHP membership committee and provides a valuable resource to the society when information needs to be disseminated to all health-system pharmacies. In addition, the selfassessment response rates were initially low. The planning committee increased response rates by personally contacting pharmacy directors to encourage participation. The conversion of the recommendations into committee responsibilities was also challenging during the first year after the conference. We found that the charges presented to the committees during the year were initially too ambiguous in scope, and the committees struggled to identify enough direction or taskspecific responsibilities, which would provide measurable outcomes. One such example was a charge asking the committee to create, over the
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Table 1.
PPMI Recommendations Developed by Focus Groups2,a
Recommendations in Targeted Areas Acute care How do we ensure staff competency and training? MSHP develops intense continuing-education programs leading to certification for pharmacists with periodic recertification (e.g., anticoagulation management, pharmacokinetics, pain management) (n = 45) MSHP advocates for PGY1 training or equivalent experience for hospital pharmacist positions and PGY2 and/or board certification for specialized positions or for positions caring for complex patients (n = 46) MSHP advocates for ASHP accreditation of technician training programs in the state. MSHP also advocates that the state requires technician certification and registration (n = 44) MSHP advocates for the requirement of greater practical training hours for pharmacist licensure (n = 46) How do we effectively integrate all pharmacy personnel into a new model? MSHP develops a toolkit/webinars/speakers bureau to explain the PPMI to pharmacy staff to ease apprehension (n = 46) MSHP encourages pharmacy leaders to develop career ladders (n = 45) MSHP highlights innovative practice models in the state (n = 46) How do we identify and prioritize services in the new model? Pharmacy leaders should advocate for minimum pharmacy services to include drug distribution, pharmacokinetics, anticoagulation management, and antimicrobial stewardship for all practice settings (n = 46) Pharmacy leaders use data from order volumes, survey of patients, nurses, physicians, and staff in conjunction with staff consensus to develop model structure and services (n = 46) MSHP advocates for medication-related national quality indicators for hospitals and also educate on how pharmacists can obtain those goals (n = 46) MSHP grant or award for PPMI best practices (n = 46) Pharmacy leaders should align department goals with those of hospital leadership (n = 46) Ambulatory care How can we convince regulators (legislators, accreditation organizations, payers) to allow expansion of collaborative practice and prescribing? MSHP to review collaborative practice agreements in other states and analyze changes in Michigan laws to facilitate such agreements (n = 46) MPA to lobby for change in Public Health Code verbiage to include pharmacists as prescribers (n = 47) MSHP to investigate barriers for payers to pay when collaborative agreements are in place (n = 47) How do we assure pharmacy clinical services are standard (means pharmacist clinical services are always present) and payable in every ACO model in Michigan? MSHP identifies who makes decisions regarding requirements of ACO and disseminates to members (n = 47) MSHP to investigate mechanisms at the regulatory level—requirements for clinical pharmacy services including ambulatory and nontraditional in all ACOs (n = 46) MSHP to identify various return-on-investment models for pharmacy services in ACOs separate from drug product/dispensing (including dissemination to members) (n = 44)
Highest Impact and Feasibility
No. (%) Respondents in Agreement
HI-HF
21 (46.7)
HI-LF
27 (58.7)
HI-HF
32 (72.7)
LI-LF
20 (43.5)
HI-HF HI-HF HI-HF
30 (65.2) 24 (53.3) 23 (50.0)
HI-HF
27 (58.7)
HI-HF
19 (41.3)
HI-HF LI-HF
25 (54.4) 24 (52.2)
HI-HF
33 (71.7)
HI-HF
29 (63.0)
HI-HF
23 (48.9)
HI-HF
28 (59.6)
HI-HF
26 (55.3)
HI-HF
22 (47.8)
HI-HF
24 (54.6)
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Table 1 (continued) Highest Impact and Feasibility
Recommendations in Targeted Areas How do we adopt and expand innovative clinical ambulatory practice models outside the traditional setting (e.g., rural areas, retail, independent businesses)? MSHP to work with payers to establish standardized clinical pharmacy services that would be paid for at the individual pharmacist level and disseminate the information (n = 46) Create a new section in MPA for ambulatory care, infusion, and home care which will include establishing standard ambulatory clinical practice programming at the annual MPA meeting (n = 47) Develop new clinical sites by (1) collaborating with colleges of pharmacy, current residency programs, and the Michigan Colleges of Pharmacy Education Panel to utilize trainees to develop ambulatory clinical service business plan, (2) incorporating training on how to duplicate ambulatory services in different practice settings, and (3) developing electronic toolkits and clinical learning collaborative (n = 47) Education How do we increase the number of sites/positions for residency training? MSHP should provide a resource toolkit to start a residency (basic startup, value, address barriers, preceptor training, provision of an advisor for startup) (n = 45) MSHP should identify potential sites for residency programs (n = 46) Colleges of pharmacy should work with sites to determine ways they could support residency program development (n = 45) Site should create models of training beyond one-to-one training for residents and students (e.g., medical model) (n = 45) MSHP should work with sites to consider yearly expansion (increased number of positions) of their current residency programs (n = 46) How do we increase the number of rotations/sites for students? Colleges of pharmacy and MSHP should promote to sites the need and benefits to provide experiential education (n = 45) Colleges of pharmacy should work with sites to determine services that students could participate in to increase student capacity and increase service provision (n = 45) MSHP should encourage directors of pharmacy to develop department mission statements that include a culture of providing education as part of practice (n = 46) How can we integrate students or residents into active pharmacy practice to advance the practice model? Colleges of pharmacy and sites should develop a listing of skill/competencies for students at each level of training (n = 46) MSHP should work with colleges of pharmacy to develop a listing of best practices that demonstrate integration of students into practice (n = 45) Leadership How do we demonstrate and communicate our unique value in patient care? MSHP should establish a list of consistent metrics to demonstrate value of direct patient care activities (n = 46) MSHP should design a communication tool/campaign to send a consistent message to our stakeholders (n = 46) MSHP should strongly endorse pharmacists as physician extenders (n = 45) MSHP should develop a speakers bureau to train the trainer on PPMI core elements (n = 45)
No. (%) Respondents in Agreement
HI-LF
26 (56.5)
HI-HF
20 (42.6)
HI-HF
19 (40.4)
HI-HF HI-HF
35 (77.8) 23 (50)
HI-HF
27 (60)
HI-HF
28 (62.2)
HI-HF
20 (43.5)
HI-HF
22 (48.9)
HI-HF
34 (75.6)
HI-HF
20 (43.5)
HI-HF
28 (60.9)
HI-HF
38 (84.4)
HI-HF
31 (67.4)
HI-HF HI-HF
28 (60.9) 27 (60.0)
HI-HF
26 (57.8)
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Table 1 (continued)
Recommendations in Targeted Areas How do we ensure our work force is competent to practice in the new practice model? MSHP should utilize members to advocate for certification and licensure of pharmacy technicians (n = 45) MSHP should develop a tool for directors of pharmacy to assess staff and bring them up to date on the PPMI (n = 46) MSHP should support development of a competency test to assure that pharmacists’ skills match the new practice model standards (n = 46) Technicians How do we overcome real or perceived barriers in advancing the CPhT role? MSHP should work with the MSPT to promote a “changing perceptions” campaign to promote innovative technician practices (n = 46) MSHP should charge the publications committee with spotlighting innovative practices in the MSHP Monitor (n = 45) MSHP should charge the awards committee to sponsor an award for the most innovative technician practice (n = 45) How do we define, measure, and justify the role of the CPhT in practice? MSHP should develop a white paper in conjunction with PTCB on technician practice detailing studies that have been done on effects of technician practice on cost, quality, safety, and customer satisfaction (n = 46) MSHP should charge the education committee and MSPT with developing an innovative technician practice presentation for the annual meeting and various other venues (n = 43) How do we ensure that hospitals and health systems have career paths or tracks for CPhTs that encourage full participation in the healthcare team? MSHP should develop a certification page within the content of PPMI2 page to contain a toolbox with job descriptions, career ladders, and retention programs (n = 45) MSHP should communicate to directors of pharmacy where these materials are located and include examples of team participation such as safety huddles and committee participation (n = 45) How do we increase access to ASHP-accredited technician training programs? MSHP and MSPT should provide help to existing technician training programs to gain and maintain ASHP accreditation, work with existing programs for online access and Web-enabled training, hire from only accredited programs, and post link to ASHP website of accredited programs (n = 45) How do we achieve legal/regulatory environment that supports development of a pharmacy technician work force that will enhance optimal pharmacy practice model? MSHP and MSPT should charge MPA to support legislation or Board of Pharmacy rules promulgation requiring graduation from an accredited program and passing the PTCB examination and licensure of technicians (n = 45) Technology How do we use evidence-based medicine to design effective decision-support tools? MSHP should advocate pharmacist involvement in design and content of order sets (n = 47) MSHP should develop a task force to define a consensus for best practice around clinical decision-support alerts (n = 47)
Highest Impact and Feasibility
No. (%) Respondents in Agreement
HI-HF
32 (71.1)
HI-HF
25 (54.4)
LI-HF, HI-HF
13 (28.3) for both
LI-HF
23 (50.0)
LI-HF
31 (68.9)
LI-HF
29 (64.4)
HI-HF
26 (56.5)
HI-HF
21 (48.8)
HI-HF
27 (60.0)
LI-HF
25 (55.6)
HI-HF
26 (57.8)
HI-HF
29 (64.4)
HI-HF
35 (74.5)
HI-HF
37 (78.7)
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Table 1 (continued)
Recommendations in Targeted Areas How do we use information technology to improve drug distribution quality as a means to free pharmacist time (maximize bar technology)? MSHP should advocate for research to validate automated drug product selection technologies (n = 46) MSHP should advocate for the use of validated technologies that free pharmacist time to pursue patient medication management issues (n = 46) MSHP should advocate for development of regulations that support the use of validated technologies throughout the drug distribution process (n = 46) How can we create tools that can be implemented to triage/prioritize/assign potential medication-related problems? MSHP should participate in the validation of software/tools developed as part of ASHP PPMI (n = 45) How can we improve safety and efficiency of order review/verification with use of technology? MSHP should develop practice guidelines defining pharmacist expectations as part of order review and verification while incorporating the full potential of technology (n = 46) MSHP should advocate for a change in legal regulations that mandate pharmacists to review all medication orders (n = 46) MSHP should advocate for research to show which segments of medication order review can be automated while providing the same level of or greater safety than pharmacist review (n = 46)
Highest Impact and Feasibility
No. (%) Respondents in Agreement
HI-HF
29 (63.0)
HI-HF
34 (73.9)
HI-HF
30 (65.2)
HI-HF
36 (80.0)
HI-HF
33 (71.7)
HI-LF
22 (47.8)
HI-HF
32 (69.6)
PPMI = Pharmacy Practice Model Initiative, HI = high impact, HF = high feasibility, LF = low feasibility, LI = low impact, MSHP = Michigan Society of Health-System Pharmacists, PGY1 = postgraduate year 1, PGY2 = postgraduate year 2, MPA = Michigan Pharmacists Association, ACO = accountable care organization, CPhT = certified pharmacy technician, MSPT = Michigan Society of Pharmacy Technicians, PTCB = Pharmacy Technician Certification Board. a
next five years, a strategy to highlight advances that health systems in Michigan have made with respect to the PPMI and PPMI2 initiatives. Subsequently, MSHP annual goals were developed with more-specific outcomes defined, such as developing a listing of minimal pharmacy services to be provided, to serve as a guide for PPMI progress. It was recognized by MSHP leadership that many of the recommendations would take several years to complete. To ensure that MSHP maintains its focus on the PPMI2 recommendations, the PPMI2 planning task force transitioned into the strategic planning council. This council monitors progress toward achieving the recommendations set forth by the PPMI2 conference. The council provides guidance to the MSHP board in regard to the strategic plan and continuity of the overall mis-
sion and goals of MSHP. Use of the ASHP hospital self-assessment tool provided us with a pharmacy practice model snapshot within Michigan before the PPMI2 conference. Moving forward, we plan to use the self-assessment tool to evaluate the impact of the conference and MSHP initiatives and the progress toward achieving PPMI goals. Recommendations developed during the PPMI 2 conference are ambitious goals, which will likely take time to implement and achieve. Utilizing the talents and teamwork of MSHP members, MSHP believes it is moving in a direction that will help provide assistance to all healthsystem pharmacies across Michigan. This support will allow the transformation of their practice into an optimal model so they are consistently providing safe, effective, efficient, accountable, and evidence-based care
for all patients in health systems. To further our vision for health-system pharmacy practice, MSHP planned a similar conference for September 2014 to focus on the ambulatory care environment, transitions of care, and continuity of care utilizing information from the ASHP Ambulatory Care Conference and Summit. Conclusion A process for acting on recommendations of the ASHP PPMI to advance the practice of healthsystem pharmacy within the state of Michigan was developed. References 1. Executive summary. Am J Health-Syst Pharm. 2011; 68:1079-85. 2. The consensus of the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1148-52. 3. American Society of Health-System Pharmacists. PPMI hospital self-assessment tool. http://ppmiassessment.org/ (accessed 2013 Aug 20).
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