Ensuring the Best Use of Medicines in Hospitals and Health Systems

Executive Summary

The ASHP Vision for the Pharmacy Workforce in Hospitals and Health Systems expresses a vision for building the workforce capacity of pharmacy departments in hospitals and health systems to meet the growing challenges related to optimizing the use of medicines in those settings.

Challenges

The scientific knowledge about drugs and the professional knowledge about pharmacy service delivery expand continuously. Many patients in hospitals and health systems in the United States have serious, complex, and urgent health problems that require advanced diagnostic evaluations, intricate medical procedures, and aggressive care. Medication use in hospitals and health systems is a prominent therapy for virtually all patients, and it is inherently complex and dangerous.

Pharmacy Functions

The objective of the overall pharmacy function in hospitals and health systems is to support sound patient care through the safe, evidence-based, and cost-beneficial use of medicines. Hospitals and health systems—in part because of demands by the government and external quality bodies—will require that pharmacists and pharmacy technicians possess and maintain sound credentials attesting to their competence to handle the tasks assigned to them. The overall pharmacy function in hospitals and health systems includes:

• Reviewing individual patients’ medication orders for safety and effectiveness and taking corrective action as indicated.
  
• Collaboratively managing medication therapy for individual patients.
  
• Educating patients and caregivers about medications and their use.
  
• Leading continuous improvements in the medication-use process.
  
• Leading the interdisciplinary and collaborative development of medication-use policies and procedures.
  
• Acquiring quality drug products from trusted supply sources.
  
• Preparing medications in the doses and dosage forms needed.
  
• Distribution of medications to inpatients and outpatients.
  
• Ensuring the availability of quality drug information.
  
• Influencing drug administration policies, procedures, and the use of related devices.
  
• Conducting quality reviews of medication utilization in the hospital’s or health system’s population of patients and seeking improvements where indicated.
  
• Leading and influencing decisions about medication-related informatics, other technology (including drug administration devices), and automated processes in medication use.

The most effective pharmacy departments coordinate and integrate these functions into a cohesive whole, bringing together a team of pharmacists, pharmacy technicians, and others that have differentiated roles in management, patient care, medication-use policy, quality improvement, informatics, and drug product preparation and distribution.

Vision for Teamwork. Overall medication-use processes (which include prescribing, order review, dispensing, administration, monitoring, and adjusting therapy based on patient response) will be carried out by interdisciplinary teams, and pharmacists will continue to be the only health professionals with the depth and breadth of knowledge about, and the interest to focus their full time leadership attention on, the use of medicines.

Vision for Technology. Hospitals and health systems will continue to be technology-intensive environments. Shortages of pharmacists and pharmacy technicians qualified for work in hospitals and health systems are expected to be chronic. Technology will not eliminate these shortages. The use of technology will remain incomplete and nonstandardized (an important safety issue in itself) for some time.

Vision for Pharmacists’ Responsibilities. Increasingly, pharmacists will apply their time to direct, interdisciplinary patient care to ensure the best use of medicines by individual patients. A growing number of pharmacists will work in highly specialized therapeutic areas. The expanded use of uniformly educated and certified pharmacy technicians will permit a larger portion of a pharmacy department’s pharmacist staff to focus on direct patient care activities.

Credentials

Licensure alone will be insufficient for pharmacy practice in hospitals and health systems.

Vision for Residencies. Hospital and health-system employers will expect all entry-level pharmacists to have completed an ASHP-accredited first-year postgraduate pharmacy residency. First-year residency programs in hospitals and health systems concentrate on developing pharmacists that understand the organizational environment, can work in that environment to provide clinical care to individual patients, are capable of interdisciplinary professional work at both an organizational and clinical level, understand the internal and external standards of quality that apply, and are adept at measuring and documenting metrics of success to manage quality.

Vision for Specialty Certification. Second-year ASHP-accredited postgraduate residencies will be required for pharmacists caring for highly specialized and complex patients. These programs prepare pharmacists to effectively interface with specialized physicians and nurses and manage pharmacy services and informatics. Pharmacists who provide services in an area in which specialty certification exists will be expected to be certified in that specialty.

Vision for Leadership. All hospital and health-system pharmacists will be required to refresh their credentials continuously and to engage actively in personal continuing professional development. Strong leadership will be required to provide and sustain comprehensive professional vision for pharmacy departments. Pharmacy managers will possess credentials appropriate to the scope of services and the size and complexity of the setting, including, in many cases, advanced graduate degrees in pharmacy or nonpharmacy disciplines. Pharmacy departments will be headed by pharmacists; nonpharmacist managers will handle many tasks that do not require the expertise or judgment of a pharmacist.

Vision for Pharmacy Technicians. Pharmacy technicians eventually will be defined in laws and regulations as those individuals working under a pharmacist’s responsibility that (a) have completed an ASHP-accredited pharmacy technician training program, (b) are certified by the Pharmacy Technician Certification Board, and (c) are registered with state boards of pharmacy.

Achieving the Vision

ASHP is assessing what it and others need to do to achieve this vision for the pharmacy workforce in hospitals and health systems. Future programs and advocacy of ASHP will be based on this assessment.

Introduction

Medication use in hospitals and health systems is complex and inherently risky. The American Society of Health-System Pharmacists (ASHP) believes it is inevitable that public policymakers, hospital and health-system administrators, and others will seek to modify the roles and required credentials for the pharmacy work force in those settings to ensure that medication use is safe, effective, and appropriate. ASHP believes the decisions will be best guided by a long-range vision about the pharmacy work force for those settings.

This vision is consistent with the ASHP Vision Statement for Pharmacy Practice in Hospitals and Health Systems,¹ the ASHP Health-System Pharmacy 2015 Initiative,² and the future vision of pharmacy practice³ developed by the Joint Commission of Pharmacy Practitioners. This document serves as

• An expression of ASHP’s continuing aim to support the development of competence building, sound credentials, and credentialing and privileging processes for pharmacists and pharmacy technicians in hospitals and health systems,
  
• A guide for ASHP in its long-term development of policies, education, publications, and activities to help pharmacists and pharmacy technicians develop and maintain the competence and credentials needed to work in hospitals and health systems, and
  
• An advocacy tool to stimulate public policymakers, external quality standards groups, hospital and health-system trustees and administrators, hospital and health-system pharmacy directors, and leaders in other collaborative health professions to ensure that the pharmacy work force in hospitals and health systems is appropriately competent, has the appropriate credentials, and is appropriately privileged on the basis of credentialing processes.

Hospitals and Health Systems

Hospitals and health systems include individual hospitals, multiple-hospital systems, health maintenance organization clinics, hospital-affiliated predischarge and postdischarge clinics, hospital-based ambulatory care pharmacies, home care services, rehabilitation facilities, skilled-nursing facilities, and assisted-living facilities. Common to all of these settings are the health-system characteristics of (1) an interdependent and interdisciplinary work force, (2) collaboratively developed and evidence-based medication-use processes, (3) a governance structure that is accountable for safe, effective, and appropriate patient care, (4) multiple levels of care with continuity of care among these levels, and (5) an ongoing assessment of performance using externally established quality standards and accreditation requirements.

The Overall Pharmacy Function in Hospitals and Health Systems. Pharmacists and pharmacy departments bear professional and legal responsibility for all medication-use activities in hospitals and health systems. That responsibility is abundantly clear in professional standards, statutes, regulations, court precedents, and external quality standards. The overall pharmacy function in hospitals and health systems will continue to include

• Leading the interdisciplinary and collaborative development of medication-use policies and procedures within the setting, including pharmacy and therapeutics committee policies and therapeutic protocols,
  
• Reviewing patients’ medication orders for safety and effectiveness,
  
• Collaboratively managing medication therapy for individual patients,
  
• Educating patients and caregivers about medications and their use,
  
• Leading continuous improvements in the quality of medication-use processes,
  
• Acquiring quality drug products from trusted supply sources,
  
• Preparing medications in the doses and dosage forms needed,
  
• Distributing medications to inpatients and outpatients,
  
• Integrating the work of staff in clinical and other functions to ensure coordinated attention to safe, effective, and appropriate care,
  
• Functioning as a gatekeeper with respect to the quality of drug information available to caregivers throughout the setting as a means to support up-to-date, evidence-based care,
  
• Influencing drug administration policies and procedures and the use of related devices,
  
• Conducting quality reviews of medication utilization in the hospital or health system’s population of patients, and
  
• Leading and influencing decisions about medication-related informatics, other technology (including drug administration devices), drug administration, and automated medication-use processes.

Differentiation and Teamwork. In hospitals and health systems, the overall pharmacy function will be accomplished via a differentiated pharmacy work force that includes managers, pharmacists practicing in direct inpatient and outpatient clinical roles, pharmacists and pharmacy technicians in inpatient and outpatient drug preparation and logistical distribution, pharmacists leading informatics and other technology activities, pharmacy technicians, business and operations managers, and other personnel, including informatics assistants, secretarial and administrative assistants, clerks, stock-handling personnel, and couriers. Differentiation in the pharmacy work force will increase with the size and scope of hospitals and health systems. Differentiation will be most pronounced in academic health centers where there are additional missions of education and research. Overall medication-use processes will be conducted by interdisciplinary teams. Pharmacists will continue to be the only health professionals with the depth and breadth of knowledge about—and the interest to focus their full-time leadership attention on—the safe, effective, and appropriate use of medicines.

Technology. Hospitals and health systems will continue to be technology-intensive environments. Many of the technologies, including those for automated medication delivery, pharmaceutical compounding, pharmaceutical packaging and labeling, automated distribution and vending, bedside verification, drug administration (e.g., infusion pumps), electronic drug information, electronic communications, and electronic patient records, will influence medication use. Automation and information technology will be increasingly integrated into medication-use processes. Pharmacists with technology and informatics expertise will influence the choice and use of technologies to ensure patient safety, effectiveness of care, and efficiency.⁴ As new technologies evolve, pharmacists will ensure that these preserve and enhance medication-use safety, effectiveness, and appropriateness.

Leadership. Ongoing pharmacy leadership and management will be required to provide and sustain a comprehensive professional vision and evidence-based medication use via an integrated and interdisciplinary work force and to apply limited resources to activities that will be the most effective. Leadership and management will be required at all levels, including clinical practice, to ensure that the overall pharmacy function successfully influences the care of patients. In successful pharmacy departments, middle management positions will exist, and qualified personnel at all levels will be mentored for leadership and advanced-level positions. Hospitals and health systems in which this does not occur will be vulnerable to lapses in quality when inevitable turnover occurs in top management positions. Therefore, ongoing investment in succession planning will be essential. In large hospitals and multiple-facility systems, some pharmacists will be corporate-level directors (e.g., vice presidents). Some will have responsibility for departments in addition to pharmacy.

Pharmacies and pharmacy departments in hospitals and health systems will continue to be headed by pharmacists. In most cases, major positions below the department head level are currently occupied by pharmacists. However, it is likely that nonpharmacists will increasingly be employed below the department head level to handle various tasks that do not require the expertise or judgment of a pharmacist. These tasks may include secondary management, finance, personnel administration, quality assurance, informatics and technology, and supply and distribution logistics. Nonpharmacist positions of these types may be more common in large, complex hospitals and health systems where a differentiated work force is more necessary and possible.

Experiential Learning. Hospital and health-system pharmacists and pharmacy technicians will attain their knowledge, skills, and abilities in various ways. All pharmacists and pharmacy technicians will receive on-the-job orientation, training, and experiences that hone their knowledge and skills necessary for specific workplaces. New pharmacy college graduates will continue to be prepared primarily to deliver individual patient care. They will have in-depth knowledge about medications, their pharmacology, and their therapeutic uses. The Accreditation Council for Pharmacy Education’s (ACPE’s) accreditation standards for doctor of pharmacy degree programs require colleges to include experiential education in community pharmacy, ambulatory care, a hospital or health-system pharmacy, and inpatient or acute care general medicine.⁵ These learning experiences are expected primarily to involve direct patient care rather than learning to navigate and fully influence the interdisciplinary and multidepartmental aspects of medication use within hospitals and health systems. Concerns exist about the capacity of hospitals and health systems to accommodate the growing volume of pharmacy students needing this experiential education. Most new graduates entering hospital and health-system practice will continue to require substantial further education in order to fully function in those settings. As a means to achieve that education, they should—at minimum—complete an ASHP-accredited pharmacy residency. Some hospitals and health systems may create mechanisms for existing staff to enroll in such residencies.

Pharmacists’ Responsibilities

In hospitals and health systems, all pharmacists will be responsible for error prevention, patient safety, and patient outcomes related to medication therapy. Many will work at various supervisory and management levels in the acquisition, preparation, and dispensing of drug products, operating facilities and equipment for those activities, ensuring the supply and integrity of drug products, providing evidence-based drug information to other professionals and patients, managing the technology applied to medication use, monitoring the quality of pharmacy services, and conducting medication-use-safety activities. Some pharmacists will be engaged in sterile compounding. Some will influence the selection and management of technology and information systems for medication use. Depending on the role of the hospital and health system in education, some pharmacists will educate and train pharmacy students, residents, and pharmacy technicians. All pharmacists will appropriately balance their roles as employees of the setting and their autonomous public professional obligations on behalf of patients.

Increasingly, and dependent partly on the expanded use of uniformly trained and educated pharmacy technicians certified by the Pharmacy Technician Certification Board (PTCB), pharmacists will apply their time to direct, interdisciplinary, and collaborative drug therapy to ensure that the medication therapy of individual patients is effective, evidence based, safe, and cost-effective.⁶ Some pharmacists will work in highly specialized clinical areas. Specialists will train and support generalist pharmacists. To ensure a high level of coordination by all components of the pharmacy function in hospitals and health systems and appropriate medication use and safety, the work of clinical pharmacists will be integrated with other aspects of the overall medication-use process. Depending on the volume of clinical work required, most pharmacists will have some ongoing work assignments and responsibilities in medication distribution. Hospitals and health systems will require that all clinical pharmacists and faculty of colleges of pharmacy working in their facilities be credentialed through the routine processes used for all other pharmacy staff and be managed by the department of pharmacy.

Throughout the work setting, the acquisition of patient medication histories and the provision of discharge medication information to patients and downstream caregivers will be managed by pharmacists. This will facilitate continuity of care, reconciliation of medication regimens, and avoidance of medication-related problems. Pharmacists will ensure that necessary clinical monitoring of laboratory test values occurs pertinent to medication use for individual patients. They will engage in disease prevention activities on behalf of patients. Pharmacists will influence the selection of authoritative, evidence-based drug information that is made available to all caregivers in the workplace. They will engage in interdisciplinary development of systemwide policies, procedures, and therapeutic protocols about medica-tion use. They will engage in medication-related public health activities on behalf of their communities.

Medication-Use Process. Pharmacists will continuously improve and collaboratively redesign medication-use processes to optimize patient safety and improve patients’ health-related quality of life. They will ensure that medication-use processes incorporate system characteristics of interdependency, checks, and immediate safety feedback mechanisms. In addition to caring for individual patients, pharmacists will ensure that the outcomes of medication therapy are assessed and managed on both a systemwide and patient population basis.

Interpersonal Skills. Pharmacists in hospitals and health systems will possess exceptional interpersonal skills, work well in interdisciplinary teams, and lead the development of medication-use policies and procedures to meet patients’ needs. They will possess competence in caring for and effectively interacting with patients from a variety of cultures. They will engage in behavior and activities that promote the pharmacy profession and will represent the profession in a positive light and promote its goals.

Proliferation of Potent and Complex Medications

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