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2018 CSHP Forum: Summary Report

Hospital Pharmacy in Canada Survey

CANADIAN HOSPITAL IN PHARMACY LEADERSHIP CONFERENCE SHERATON HOTEL, TORONTO, ONTARIO FEBRUARY 2, 2018

CSHP HOSPITAL PHARMACY IN CANADA SURVEY | www.cshp.ca/hospital-pharmacy-canada-survey

2018 Forum, CSHP Hospital in Pharmacy Canada Survey: Summary Report – Feb 2, 2018 1 | P a g e

This report provides a summary of the findings of the facilitated discussions held during the 2018 CSHP Forum on the Hospital Pharmacy in Canada Survey, 2016/2017. The Board Editors who facilitated the themed roundtable discussions have summarized the results of the day. What follows are their summaries. We thank all those who participated.

Table of Contents

Opioid Crisis Management and Leadership Effect of Legalizing Marijuana on Medical Use Page 5 NAPRA Standards for Sterile Compounding Page 7 Clinical Pharmacy Key Performance Indicators (cpKPI) and Evaluating their Services Page 9 Transitions of Care Page 10 Resource Management Page 14

Welcome and Introductions

Richard Jones, Executive Editor, CSHP Hospital Pharmacy in Canada Survey Board, welcomed participants, on behalf of the Editorial Board of the CSHP Hospital Pharmacy in Canada Survey Board, to the first CSHP Hospital Pharmacy in Canada Forum. Participants received insights to key findings from the most recent survey, 2016/2017, and had an opportunity to meet and network with leadership peers from across Canada. There was dedicated time to discuss key issues relevant to all hospital pharmacy leaders in Canada. Richard Jones thanked the Editorial Board members:

André Bonnici, Quebec

Jean-François Bussières, Quebec

Douglas Doucette, New Brunswick

Kyle MacNair, Manitoba

Debra Merrill, Ontario

Allan Mills, Ontario

Chuck Wilgosh, Managing Editor, Alberta

Carolyn Dittmar, Managing Editor, Ontario

Paul Oeltjen, Research Analyst and Programmer, Quebec The following key issues facing leaders in pharmacy in 2018 were discussed in roundtable format, facilitated by the Editors listed below. The final results were shared with the attendees and are summarized herein.

Opioid Crisis Management and Leadership - Andre Bonnici

Medical Marijuana and NAPRA Standards - Debra Merrill

cpKPI Evaluation - Douglas Doucette

Transition In Care - Kyle MacNair

Resource Management - Allan Mills

For more information on the CSHP Hospital in Pharmacy Canada Survey, please visit us online at www.cshp.ca/hospital-pharmacy-canada-survey.

http://www.cshp.ca/hospital-pharmacy-canada-survey


Opioid Crisis Management and Leadership

Facilitator: André Bonnici Chef du department de pharmacie, McGill University Health Centre, Montreal, QC

In 2016, Health Canada issued a joint statement of action to address the opioid crisis. Many health professionals associations and colleges, including CSHP and all pharmacy colleges in Canada, joined this call to action. Health Canada states: “Canada is facing a national opioid crisis. The growing number of overdoses and deaths caused by opioids, including fentanyl, is a public health emergency. This is a complex health and social issue that needs a response that is comprehensive, collaborative, compassionate and evidence-based.” Dr. Theresa Tam, chief public health officer of Canada, recently said Ontario, Quebec and Manitoba have yet to report all of their opioid-related overdose deaths for the first half of the year. But based on figures reported by the other provinces and territories, the number of overdose deaths are on pace to surpass 4,000 by the end of the year — far above last year's tally of 2,861 opioid-related fatalities. Car accidents, in contrast, killed about 1,850 Canadians in 2015, the last year for which data is currently available. What can we, as hospital pharmacy leaders, do to prevent patients from becoming opioid-addicted after a hospital encounter and reducing the opioid “reservoir”? Here are a few conclusions from recent studies to help orient the debate:

“Postoperative prescription opioids often go unused, unlocked, and undisposed, suggesting an important reservoir of opioids contributing to nonmedical use of these products, which could cause injuries or even deaths.” “Approximately 3% of previously opioid naïve patients continued to use opioids for more than 90 days after major elective surgery. Specific patient and surgical characteristics were associated with the development of prolonged postoperative use of opioids.” “Ideally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.” “Transitions from acute to long-term opioid therapy can begin to occur quickly: the chances of chronic use begin to increase after the third day supplied and rise rapidly thereafter. Consistent with CDC guidelines, treatment of acute pain with opioids should be for the shortest durations possible. Prescribing <7 days (ideally ≤3 days) of medication when initiating opioids could mitigate the chances of unintentional chronic use.” What came out of the roundtable discussions? Issues and questions raised: In health care institutions, the pharmacy department is ultimately responsible to ensure opioids are stored and dispensed in a controlled manner both in the pharmacy as well as on patient care units. The pharmacy is also responsible to ensure opioids are prescribed safely both in the hospital and upon discharge. There is an opportunity for improvement in many areas:

https://www.tc.gc.ca/eng/motorvehiclesafety/tp-tp3322-2015-1487.html

https://www.tc.gc.ca/eng/motorvehiclesafety/tp-tp3322-2015-1487.html


At the pharmacy dispensing level:

No specific guideline by Health Canada or provincial authorities on what is an acceptable mean of control (double check for example) at all stages of the dispensing process.

What should be the frequency of complete narcotic inventory counts within the pharmacy inventory?

When should management be involved and at what frequency to audit control process within the pharmacy?

At what frequency should wastage of expired and returned narcotics be done?

How should we dispose of “patient’s own” narcotics?

How should we restrict access to narcotic vaults? Pharmacists, Technicians, Security?

On the patient care units:

What should be the frequency of complete narcotic inventory counts?

What is the responsibility of the nursing managers in dealing with control and discrepancies in counts?

What frequency should pharmacy audit patient care areas? Should this be different when automated cabinets are present?

Should all narcotic withdrawals be witnessed and countersigned? Should all wastage be witnessed and countersigned?

Prescribing:

Teaching how to prescribe opioids safely to physicians does not seem to be prioritized in medical programs at the present time

Pre-printed orders, especially at discharge, may contain quantities of narcotics that exceed needs and may put patients at risk of developing addiction or adverse event

Control of opioids in Operating rooms is difficult and often not ideal. Anaesthesiologists are at particular risk as they are both the prescriber and the professional who administers the opioid.

Drivers: Opioid addiction and death caused by opioids is now recognized as a crisis in North America. Part of the problem stems from practices within the health network. The public is looking to health professionals and health care leaders to step up and implement changes to reduce risks and curb inappropriate practices that increase risk of harm from opioids. Hospital pharmacy managers and directors hold many of the levers necessary to reduce risks of opioid diversion and to implement policies promoting safe opioid prescribing practices. Solutions: discussions at the roundtable highlighted some of the good practices already in place in certain institutions. Some consensus ideas to consider on the short-term as well as some very bold, provocative ideas were put forth to improve opioid dispensing and prescribing. Pharmacy dispensing:

Consensus:

Technologies such as automated dispensing cabinets in the pharmacy narcotic vaults should be considered for all hospital pharmacies

Camera surveillance in the narcotic vault should be present for all hospital pharmacies (or around pharmacy narcotic cabinet if no vault)


Pharmacist leaders / managers should be directly involved in auditing narcotic dispensing process, weekly or bi-weekly with the pharmacy

All pharmacy departments should have a detailed policy and procedure covering all aspects of opioid and controlled drugs management

Access to the pharmacy narcotic vault should be restricted to pharmacy personnel only. Access by security or building management should be pre-authorized by a pharmacist for emergencies (e.g. fire) only.

Other proposed solutions (No consensus)

Should technician check technician be implemented at all stages of the narcotic dispensing process?

Should employees involved in pharmacy dispensing of narcotics be tested (urine test for example)?

Should external audits be done (Health Canada should likely be doing this already)?

Patient care units:

Consensus:

Reconciliation of opioids moving from pharmacy to the nursing unit should be systematic.

Wastage of opioids should be countersigned by 2 nurses (or anaesthetist and nurse in OR for example)

Discrepancies should be managed immediately (including for automated dispensing cabinets)

Narcotics should not be pre-drawn in syringes by nurses or anaesthetists

Documentation of dosage and patient identification on a narcotic registry (electronic or paper) must be mandatory for nurses and anaesthetists

Audits should be performed randomly by pharmacy to verify documented dose VS patient record

Electronic audits using specialized software should be encouraged (for example software that analyzes usage by user / outliers in automated cabinets)

Other proposed solutions (no consensus)

Nurses and anaesthetists should undergo random urine testing

Audits of syringes using spectrometry should be done in the OR randomly to confirm presence of opioids

Propofol should be locked up and controlled just like a narcotic

Cameras in each OR theater should be positioned to film area where narcotics are handled

Prescribing:

Consensus:

All pre-printed order sets containing narcotics must be reviewed by P&T, including reviewing already approved order sets in order to ensure safe opioid practices are integrated

Pharmacy departments should be actively involved in teaching health professionals safe opioid prescribing practices. Dosages, multimodal pain control, appropriate duration and tapering of opioids should be addressed among other topics.

Audits of opioid prescriptions including discharge prescriptions, should be done and individual physician feedback be officially given via medical department heads. (e.g. opioid prescribing “report card”)


Other proposed solutions (No consensus)

Follow-up patient calls by pharmacist should be considered to verify pain control and opioid usage, especially for high-risk patients

Hospital pharmacists should verify all discharged orders containing an opioid prior to patients leaving and appropriate counselling to patients should be systematic.

A set limit number of tablets for opioid should be determined for discharge prescriptions

Effect of Legalizing Marijuana on Medical Use

Facilitator: Debra Merrill, Director, Pharmacy Program Royal Victoria Regional Health Centre, Barrie, ON

Medical versus Recreational Use Issues:

1. When the Cannabis Act (Bill C45) is passed, the Controlled Substances Act will be amended to remove cannabinoids

a. Will no longer be considered a controlled substance which will change how we legally prescribe/procure/store/document medical marijuana (MM)

2. Access will potentially change: a. Patients requiring MM may or may not use a designated distributor as they will now be able to

procure through a retail facility (e.g. LCBO in Ontario)

Provincial Variations:

1. Quebec has a well-established process which likely will not change; they are mandated to supply for in-patients if it is for medical purposes

2. In NB, no form of cannabis is allowed in hospitals 3. In some provinces, it will be individual hospitals to deal with this; in others, a regional approach will be

taken

Hospital Specific Issues:

1. Should it be Patient’s Own & they are accountable/responsible for: a. Procuring b. Storing at the bedside

2. Should it be considered for Formulary?

a. No DIN but yet we need to enter into our IT systems for: i. Decision support tools such as drug/drug interactions

ii. Appearing onto MARs (computerized or electronic) for administration b. Making it Formulary legitimizes it as a drug and some Physician Colleges have made strong

statements against this (e.g. CPSO in Ontario) c. If Formulary, then is the hospital accountable for procuring for all patient use? d. Some hospitals are designating these products under Herbals while others are not even

permitting them; some will continue to put them in their ADC’s while others will not as they are not technically considered a drug


e. Decisions will need to be addressed around ‘new starts in hospital’ versus continuation of therapy from home, as well as how or if dosing changes occur

3. Entering it into our IT systems will require: a. Databases that include this in their decision support tools b. Creating new routes of administration c. Determining new ‘dose’ terminology (e.g. # of buds) d. Do we have multiple entries for Med Rec re: medical use versus recreational use as even

recreational use will impact evaluation of other medication assessment needs

4. Access: a. If using the patient’s own distributor, billing systems need to be set up b. Once the Cannabis Act is passed, what does this mean in regards to the list of Designated

Distributors or will regulations go back to a system like when hospitals could order from the provincial liquor control board’s facilities

c. If using an alternate source for the supply of MM in hospitals, how will we determine equivalent potency of THC/CBD content

d. What are the implications to barcoding e. Can use ‘Patients Own’ but this could be challenged by the patients f. Will there be a role for GPO’s for:

i. Products on contracts ii. Lock-boxes & administration devices

5. Clinical Services:

a. What will be the pharmacist’s clinical role in managing use of MM b. Currently we ask for proof of use to validate use as MM. What will this look like after passing of

the Cannabis Act c. We need a NAPRA guidance statement on MM d. We need provincial pharmacy colleges’ statements on the management of MM in hospitals

Risk Management Issues in the Hospital:

1. Diversion by staff if it is not accounted for like other controlled substances 2. Diversion by Visitors 3. Protection of the Patient 4. Vaping & smoking:

a. Legislation exists around smoking in public places which needs to be considered b. Some organizations have created rooms for this (e.g. CAMH in Ontario)

5. Some hospitals are already developing PPOs in order to attempt management of withdrawal in the ED as well as assessing effectiveness/monitoring

Issues in the ED & Lessons Learned from Countries/States where this Exists:

1. The Colorado Experience has shown an exponential increase in ED visits since legalization of marijuana.


NAPRA Standards for Sterile Compounding

Facilitator: Debra Merrill, Director, Pharmacy Program Royal Victoria Regional Health Centre, Barrie, ON

Provincial Variations:

1. Each province has their unique approach to meeting NAPRA Standards b. Quebec started 10 years ago & now is in compliance c. NB set out project plans to assist institutions with a phased-in approach d. ON set a hard timeline of January 01, 2019 to be in compliance e. Some provinces have taken the approach of advising to meet the standard

2. Advisory Boards have been created in some provinces to look at a list of compulsory standards versus ‘nice to have’ standards

3. Quebec’s APES has developed a system to certify individuals who can certify staff to meet the staff (created a pool of resources to meet provincial needs)

Factors to Consider when Advocating for the Required Funds:

1. Organizational competing programs/projects, other safety issues

2. Use requirements from licensing bodies/Accreditation Standards to persuade 3. When presenting, put it into terms non-pharmacy individuals can relate to:

a. Example compare it with an OR sterile suite etc b. Use phrases such as ‘industry standards’

4. If the organization is to undergo redevelopment, is there opportunities as there will be requirements to meet current industry standards

5. There was concern expressed that even when standards are met, they can change such that before the renovation is even completed, it no longer meets a new standard

6. Other concerns included the lack of individuals/consultants with true expertise in facility design for sterile compounding (both hazardous & non-hazardous)

Models to Consider:

1. On-site capacity: having a sterile suite(s) and processes to meet standards 2. Outsourcing to a DPPs 3. Developing of a Regional Model/Centralized Facilities

a. Could also be a model when there are multiple facilities that are not compliant: pool resources to bring one facility up to compliance & service all

4. Decentralizing to patient care areas in institutions with very low volumes a. NB: will still need to meet standards for just-in-time compounding for administration

Factors to Consider when Determining the Model:

1. For older facilities consider the cost of outsourcing versus renovation costs 2. Consider the volumes required on an annual/weekly basis to determine cost effectiveness of building a

sterile suite to standards versus outsourcing 3. What does compliance with NAPRA standards really mean? What are the minimum-standards based on

evidence? 4. What are the consequences of non-compliance?


5. What are the time-frames to meet compliance: short time-lines will result in a different decision than if there is sufficient time to plan & save for the cost of the renovations

6. Are DPPs required to meet the same standards as hospitals from both a stability & sterility perspective

Beyond Use Dating & Wastage:

1. Education is lacking in regards to truly understanding BUD 2. Sunnybrook (Scott Walker) in Toronto Ontario, is doing research into sterility variability & is due to be

published later this year. As it is truly research & therefore evidence based, it could have an impact on NAPRA Standards around BUD

3. There is provincial variability around adopting NAPRA standards on BUD. For example, some oncology drugs have been given extensions based on research at the university level in Quebec

4. Research underway includes: a. Wipe testing b. Use with CSTDs c. Oncology wastage cost implications (St. Joseph’s, Toronto)

5. Cancer Care Ontario has a working group to look at wastage mitigation strategies 6. Some hospital pharmacies have been using incubators to test their results. Issue: this is against some

provincial laboratory standards

Ongoing Costs to the Organizations:

1. Annual recertification costs: a. Multi-site supports to meet standards b. Use of a third-party commercial company to meet standards

i. Sending staff to an off-site location for training ii. Bringing up a certifier to recertify multiple staff

2. Cost of supplies to do the recertification: a. Growth media b. Gowns, gloves etc c. Laboratory processing costs

3. Cost of education 4. Consideration: some organizations are choosing to only allow select individuals to be trained to perform

sterile compounding to reduce the on-going costs of recertification (e.g. only techs, not pharmacists; only some techs & some pharmacists, etc)

5. Costs for the required on-going documentation and Policy & Procedure management


Clinical Pharmacy Key Performance Indicators (cpKPI) and Evaluating their Services

Facilitator: Douglas Doucette, Regional Pharmacy Clinical Manager Horizon Health Network Moncton Hospital, NB

Until recently, there was no consensus on process or outcome measures that should be used to ensure consistent delivery of direct patient care pharmacy services Canadian consensus cpKPI Importance of implementing, measuring and reporting cpKPIs

For patients, shows accountability and impact of pharmacists on patient care

For pharmacists, consensus cpKPIs guide prioritization of patient care activities (in our practice)

For leaders, metrics show value of practitioners, guide improvement initiatives & evaluation of performance

Based on HPC Survey results, hospital pharmacy depts. struggle with evaluating pharmacy services

2016/17: 63% of sites (47% in 2013/14) use structured approach to prioritize pharmacist services (83% for teaching, 56% for non-teaching sites)

Methods used to evaluate direct patient care pharmacy services include: self-evaluation (76%), retrospective chart review (56%), direct observation (50%) & peer-review (38%)

Aspects of practice evaluated include: documentation conformity (90%); developing individualized pharmacy care plan (64%); medication counseling & evaluation of adherence (28%); answers to drug information questions (18%).

National cpKPI Collaborative – 5-year priority initiatives and current status (ranked highest to lowest):

cpKPI National Registry information capture system – pilot testing in progress

Collaborative website – to enhance communication & sharing

Patient & interprofessional feedback on cpKPI – in progress

Advocacy – seek national & provincial organizational endorsement of cpKPI

Outcomes research – impact of receiving cpKPI on patient mortality, readmissions, etc.

Pharmacy learner-Pharmacist partnership impact on cpKPI – in progress

Patient prioritization – future research on which patients benefit most from cpKPI

Consensus benchmarks for each cpKPI – future research

And more! Below is a summary of the responses and themes identified by roundtable participants:

Issues

Time – To track/record cpKPIs; continuous vs intermittent collection of cpKPIs

Resources – Track cpKPIs using mobile app, existing information system (e.g. Excel, SharePoint), or manual tally sheet

Confidentiality – When cpKPI linked to patient record vs tracked as service to patient care unit

Engagement – Of pharmacy staff, other healthcare providers, patients, administrators

Definition of cpKPIs – Some varied interpretation Drivers

Value – Of pharmacy services associated with cpKPIs (compared to other existing activities with less supporting evidence) to improving quality of patient care and advancing practice

Substantiation – Need to defend pharmacy positions (FTEs)


Patient experience – Expectations for access to pharmacy services in hospitals

Benchmarks – To gauge performance within a program, facility, or across sites or provinces Solutions

Definitions – May need further refining of cpKPI definitions to ensure consistent interpretation between pharmacists

Documentation – Sharing of success stories of documentation processes and tools to allow sites to select approach which best suits their resources

Value – Engage pharmacy staff to implement services associated with cpKPIs, and accurately and efficiently gather their indicators in practice. Managers to share data (summaries, trends) with pharmacy staff, clinical teams and administrators.

Advocacy – Promote value of services associated with cpKPIs to patient outcomes and quality of care. Target patient, physicians, other team members, administrators.

Transitions of Care

Facilitator: Kyle MacNair, Regional Director – Pharmacy Southern Health-Santé Sud, Morden, MB

Summary of Roundtable Discussion (Themes are in italics) Issues

What are the significant issues preventing our pharmacy department/regional pharmacy services from taking a leadership role in insuring that pharmacists are systematically involved in Medication Management in Care Transitions (MMCT)?

Reallocation of Resources

Where no additional resources are being given for services, other services will have to be given up in order to deliver high quality MMCT.

Information and Communication Technology (ICT)

Significant issues with the interoperability of ICT systems that limits communication between care areas. Systems need to be universal in their ability to speak to each other.

Need for a universal patient identifier throughout the healthcare system.

Attitudes of Pharmacy Departments and/or Pharmacists

Potential problem with pharmacy’s overall belief that we need to be involved with transitions in care.

MMCT is not an appealing role for pharmacists, preference to acute care activities

Clarity Regarding MMCT

What is the activity or intervention that makes the most difference. o Need for a standardize taxonomy of what constituent components of MMCT (ex. reconciliation,

telephone follow-up) o Definitions are key in order to get some uniformity of interventions to be able to compare

outcomes.


Challenges around role agreement such that, even when pharmacy is willing to participate in MMCT, there may not be institutional understanding or agreement on what role pharmacy has.

Need clearer definitions of what constitutes a high-risk patients in order to target interventions.

Monitoring Challenges

Readmission rates related to medication issues is a very specific endpoint that is hard to capture outside of a research environment.

Much of the activities associated with MMCT are about cost avoidance which is a much more difficult outcome to measure. For example, how do you measure the benefit of proactively solving a drug reimbursement issue.

Drivers

What internal and factors affect the ability of our pharmacy dept/regional pharmacy service to involve pharmacy in MMCT?

Compelling Metrics

Need for the measurement of some metric within an institution for the purpose of establishing buy-in, follow-up and sustainability.

There needs to be a value proposition for the intervention rooted in some measurable metric.

Resource Decisions

Redeployment of resources from one service to another service should be guided by evidence of what services result in best patient outcomes

Patient Safety

Framing the need for appropriate MMCT with a patient safety lens may help in garnering resources and making the discussion patient-focused rather than pharmacy-focused.

What is the role of external stakeholders such as Accreditation Canada or Provincial Regulatory Authorities in driving the role of pharmacy in MMCT?

Role of Accreditation Canada (AC)

General agreement by most groups that AC had a large impact on how institutions approached MMCT.

Wished for more specificity in what was required.

Suggested a tiered evaluation of services (ex. bronze – basic single discipline responsibility, gold – comprehensive multidisciplinary).

There is a need for agencies like AC to be specific in their directives in order to remove barriers.

Health Quality Ontario (HQO) and similar Provincial Entities

HQO creating a new indicator for readmission for COPD specifically which may make it possible to capture the clinical impact of pharmacist interventions as often readmission in this population may lead to

Pharmacy departments need to keep abreast of the activities of similar entities in other provinces to capitalize on these agencies ability to assess pharmacy interventions.


Schools of pharmacy

Need to make the pharmacists role in MMCT a key part of education and practice expectation.

The earlier these skills are incorporated into the programs the better in order for those skills to be utilized during experiential rotations.

Privacy Laws

Issues around privacy and sharing of information has become a significant barrier against efforts to increase communication during transitions of care. There is a need to engage patients to advocate for pharmacy to have access to necessary information at transitions.

Regulatory Authorities

The need for more stringent requirements on what pharmacy does for patient care.

The need for regulatory authorities across healthcare professions to better coordinate on expectations. Solutions/Actions

How has your pharmacy dept/regional pharmacy service successfully involved pharmacy in MMCT?

Leveraging Pharmacy Extenders

Creating defined roles for pharmacy students and interns to operate within MMCT, for example in call-backs to patients. Once role is defined in agreement with the School of Pharmacy, imbed the appropriate training within the program.

o Employing a layered learning model that determines what activity students can be involved in at what educational level may allow some form of student involvement even in early years.

Regulated pharmacy technician have a specific role, especially in admissions processes.

Involvement of community pharmacists to increase the communication with patients in transition.

Patient call-backs using nursing callback to triage for drug-related issues that require pharmacist follow-up.

Leveraging of Technology

Employment of tele-pharmacy services where there isn’t a volume of patients/activity to justify an onsite service.

Potential role for technology to get an image capture of important aspects of the transition medication process.

There is the potential for e-prescribing to make a significant difference in the efficiency of information transfer; however, if practices around transitions aren’t improved, we risk efficiently delivering the wrong information.

Changing Attitudes to MMCT

Creation of specific roles for pharmacists and/or pharmacy technicians in MMCT. Positioning MMCT as a specialty area of pharmacy rather than an activity. Potential role for a CSHP PSN?

Creating the concept of the patient relationship and partnership as a central tenant of MMCT. The support of patients and their families can be a powerful tool to get support for pharmacy’s role.

The potential roll of primary care pharmacists a bridge in transitions of care. Their access to the family physicians who assume responsibility for patients on discharge would potentially greatly improve the quality of communication with community providers.


Pharmacist Prescribing Authority

Two schools of thought were expressed by round-table participants

For prescribing

By assuming control of the discharge prescription process there is a forced function that pharmacy becomes involved MMCT on discharge and can resolve issues upfront.

A motivating influence to pharmacists to become actively involved in the MMCT process, combatting some of the attitudes towards this role.

Pharmacists being able to write the discharge prescription could have a positive impact on patient flow. Waiting for a physician to come to the unit to write or sign the discharge orders can lead to delays in the discharge process.

Against prescribing

By taking on the prescribing role, we are enabling physicians who should be responsible for generating appropriate discharge orders to shirk responsibility

Rather than focusing on writing the prescription, focus on the oversight of the discharge prescription. This would include identifying issues related to autosubs, screening for public formulary restrictions (ex. Limited Use), and screening for other coverage issues.

Preference to work collaboratively with the prescriber to create the admission and discharge prescriptions.

Providing a Discharge Supply

Provision of a discharge supply of medications. This practice is more common in the United States and is also being investigated in some Ontario sites. This may be most beneficial to disadvantaged patients where initial discharge home may be the most challenging period.

How should the Hospital Pharmacy in Canada Survey monitor the involvement of pharmacy in MMCT through the bi-annual survey?

Assess the degree to which sites are employing pharmacy staff in care transition roles.

Add MMCT in assessment of clinical activities.

Assess utilization of prescribing rights to facilitate MMCT in those jurisdictions that have prescribing rights for pharmacists.

Assess the existence of formal MMCT programs between hospital and community.

Is there a potential way to assess what the gap is between what pharmacy programs believe they should be funded for (ie. Asking how many positions are vacant vs. asking how many positions have been requested but not granted).

Quotable Quotes

“Stop trying to prove what is proven, start measuring adherence to best practices, not try to measure outcomes that we know will result from those practice” “Think about the reality of the current state. Think about how low the bar is. The potential for literally anyone in pharmacy doing it better”


Resource Management

Facilitator: Allan Mills, Director of Pharmacy Trillium Health Partners, Mississauga, ON

Agreed upon Challenge:

Workload for pharmacy departments continues to escalate due to: o An increase in workload has been seen for most pharmacy departments

Increasing patient care complexity Generally seeing a shorter length of stay (more patient turnover) Pharmacy is taking on more tasks/care functions (example medication reconciliation) ,

Unfortunately staffing has not increased proportionally to the increase in workload

Consensus regarding increased pressure on pharmacy o Shifting roles o Increased technology (increased assignments/tasks – example IV pumps, HIS)

Question to Group:

How do we manage this situation? Can we advocate for greater resources? What is the best manner to manage the currently available human resources?

Discussion Theme 1:

Gap analysis – what care is not being provided?

How do we know where we should be?

o What is the right number of staff? What does each patient deserve/need? Technicians and pharmacists needed to complete “necessary functions

How many Pharmacists needed for standard functions (examples like discharge counseling or med rec discharge)?

Where is this stat available, i.e.: Benchmarks?

No criteria for proper analysis – standardized numbers available? o Ratio in Hospital in Canada Survey report useful. o Use Standards to get positions/prioritize? o What is an essential service? Distribution but what Clinical?

Expectations

What are the expectations of the pharmacist/Pharmacy department from different players? Patient (Patient advisory group engagement) vs pharmacist (Pharmacy department) vs non-Pharmacy vs executives

Corporate engagement and agreement on which services the RPh will provide to patients. o Define goals of care

Literature review; positive change based on EBM : use EVIDENCE to identify tasks to be performed


Pharmaceutical care should be an expectation for patient care.

Start working proactively versus reactively (crisis management)

KPI – what can we glean from this o Standardized care (collaborative care models)

MD, nursing, patient supporting the services that Pharmacy can provide.

Pharmacy to avoid duplication of care (if a group does something well (e.g. local pain management) should we “take it over” just because it is med based or let them do it and move onto other tasks?)

o Balance of acute care vs primary care

What is it that primary care should be completing versus acute care (duplication of tasks - example discharge counselling)

o Define essential services

Clinical (what is required?) o 24/7 coverage – affects conversation? (execs - when are we needed when we can go long times

without being there)

Standardization of services provided by Pharmacy. (and prioritization) o Local, regional and national? o Clinical services that should be standard?

Prove the absolute value of RPh to get more human resources. o Demonstrate quality of services, eg. BPMH nursing errors vs pharmacist/ pharmacy tech errors o Can we (are we) practicing at full scope (techs and pharmacists)?

What is being regulated/legislated o NAPRA, college inspections.

Suggested actions:

Locally define standard functions o Engage stakeholders on conversation

Patients, other HCP o Demonstrate the value of these functions throughout the organization.

can we show that we affect C-suite KPIs

decreased L.O.S., decreased ADE, decreased re-hospitalization explain role/functions and articulate care gaps

o Identify and tackle 1 activity at a time

Engage in advocacy to receive greater allocation of resources o Locally engage other Healthcare team members in advocacy o Can we engage in setting of standards

Accreditation National pharmacy standards (CSHP role?)

all patients should receive an evaluation of pharmacotherapy as part of their hospital stay

technology standards (CPOE…) o National data (survey) as a means to compare functions. Levels of activity

Avoid “race to the bottom” (reducing coverage/resources to the lowest) Benchmark (via KPI or Hospital Pharmacy in Canada survey) Use survey as a tool to identify potential local initiatives (what are others doing)


Theme 2

Allocating the our resources

Reporting on KPI as a means to review the current service/care provided? o KPI do not cover all functions (limited KPI – do not cover all potential areas of interest)

Local prioritization – good data, meaningful outcome. Data (stats) do not reflect quality of care

From a local level – identified gaps o Which patients are you not covering – gather data on this in addition to what is being covered.

o Which units are you not covering and would like to cover. o Which patients on a unit are you not covering and would like to cover

o What does this lack of coverage mean to patients?

Do we ration our resources? o Either partially provide

Partial coverage of all wards/units are complete coverage of some wards/units From a local level – identified gaps

o Can we define “core” functions (rotations) based on evidence National consensus of what we do (all stakeholders) Is it dependent on the patient populations being served?

How do we identify appropriate patients (score/value) Is there staff resistance to “defined” role

Prioritization Matrix/standards o National standards – care model

Training/ function - align with tasks from University forward Practice mode

o Some groups have worked on periodization schemes general care priorities (patients understanding their medications, making informed

choices and adherent to regimen)– select patients accordingly Bronze, silver, gold care - tasks/coverage allocated based on available resources Pyramid model – prioritise tasks based on allotted time available by pharmacist

Increased performance and quality of functions from both groups – Techs and Pharmacists o Identify the “best” way to provide care

Centralization versus decentralization o Scope of practice

Prescribing o Automation / technology o Enhance documentation of tasks/outcomes/ “added value” o Patient relationship – experience vs outcome

Standardize functions (common experience)?

Encourage the exploration of novel rolls / functions o What does the patient need? o Add new functions to structure

based on EBM – what is the care gaps / needs gather evidence as the roles are created


Suggested actions:

Determine what care is not being provided o by patient or by unit o provide a means to measure to provide data for advocacy (local, regional)

If required, consider a standardized allocation scheme o Identify which patients /roles/functions should be prioritized

Encourage the exploration of novel rolls / functions o What are the gaps in care? What does the patient need? o What can technology help support – how does this change roles/tasks/sequence of care events

2018 cshp forum, hospital pharmacy in canada … survey/cshp...pharmacy in canada forum....

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