Marc W. Mora, MD

In the April 2010 issue of The American Journal of Pharmacy Benefi ts, I discussed the reality we face in our work on pharmacy & therapeutics (P&T) committees: change has become a part of modern formulary management and care delivery, and successfully leading change is a necessary and core skill of a P&T committee’s work.

 P&T committees must change in response to new therapies and technologies. They must change in response to a changing membership structure, which may result in a different set of skills and personal experiences. They must change to be more effective.

Pharmacy & therapeutics committees continually adjust and refi ne how they incorporate evidence-based decision making into formulary development and implementation. They drive implementation of formulary changes and medication use management initiatives. Their decisions can result in changes in clinical prescribing and practice as well.

In a landmark article published in 1995, Harvard Business School Professor John Kotter reviewed the factors necessary for a successful transformation effort.

 Professor Kotter offers reasons why the transformation process may fail. I instead focus on the reverse, on the ingredients for a successful P&T process and transformation effort.

In the first article I discussed some principles that Professor Kotter identifi es as essential for change: creating a sense of urgency, building a guiding coalition, and establishing and communicating the vision and direction. In this second article, I focus on 4 additional elements necessary for a successful transformation effort and apply them to the P&T committee process.

Removing Obstacles to the New Vision or Direction

Essential to effective change management is the ability to articulate either how a formulary change creates value for patients or how the change creates savings that can be reinvested to improve patient care. The most powerful vision formulary leaders can communicate is that of a safe and high-quality formulary that improves patient outcomes and avoids harm, in addition to making healthcare more affordable.

However, changes in formulary or medication use management typically require changes in behavior. Such changes will inevitably be opposed by some. Recognizing that change may be opposed is the fi rst step in removing potential “derailers” to successful transformation. For example, implementing a switch from one drug to another within a therapeutic class may be opposed by some on the grounds of convenience or safety as proxies for quality. Committees should respond early to potential arguments against the switch. Including those arguments in communications to patients, physicians, or purchasers also can help align those groups in the change process.

Systematically Planning for and Creating Short-Term Wins

One of the most effective ways to remove obstacles is to appropriately plan for and celebrate wins. In the case of medication use management, initiatives could be in place to identify early adopters or prescribers of a new drug within a therapeutic class. Publicizing their success by sharing their prescribing data is very effective in ensuring broad acceptance of the change. In working teams who are resistant to change, celebrating high-performing groups can help lower-performing teams see that the outcome is possible and could be motivating. An explicit commitment to plan for and create early wins—and then communicate and celebrate the success&mdash;can build ongoing momentum in the transformation efforts outlined by Professor Kotter.

Pharmacy & therapeutics committee members must continuously focus on the vision of creating value for patients and purchasers. A brighter future with safer, more effective medication use is a necessary component of the transformational work we do. Implementing this vision requires ongoing attention, and the work is never finished. The formulary always can be made safer, additional medication use management opportunities always can be identified, and information regarding current or new pharmaceuticals always will come to P&T committees. Declaring victory can lessen the meaning of the work for those doing it and allow those opposed to ongoing formulary or medication use improvement to declare the work is over—we are finished!

Anchoring Changes in the Corporate Culture

Pharmacy & therapeutics committees can anchor change in their cultures and the larger medical community by continuing to publicize formulary success and recruiting committee members who are committed to the ideals and vision of the work. Physician and pharmacy committee members who believe that “this is the way we do business” are the strongest members in your guiding coalition and your most important communicators. They also carry on the traditions of the effective P&T culture, and train and orient new committee members. When the everyday work that the committee does is linked with improved outcomes—whether in safety, quality, or affordability&mdash;the work is successful. Continuing to tell the story of past and current P&T success is an effective way to build the P&T culture so that it outlasts any single committee member.

The work that P&T committees do in formulary and medication use management is in many ways about leading change. We need to respond to new information about medication effectiveness and safety, and change formularies in response to that information. Factors known to promote and sustain change include removing obstacles, planning for and publicizing successes, understanding that the work is never fi nished, and anchoring transformation efforts in the corporate culture 

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Understanding the factors necessary for successful change management will make this work more satisfying and rewarding for P&T committees.

How P&T Committees Can Be Effective Change Agents: Part 2

In medicine today, change may come quickly or slowly, episodically or constantly. It may come with difficulty or relative ease. Leading change is part of a pharmacy & therapeutics (P&T) committee’s responsibility. Committees change in response to the review and implementation needs of new therapies and technologies. They change based on new members who bring different

sets of skills and personal experiences, and they change to be more effective. They must continually adjust and refine how they incorporate evidence-based decision making into formulary development and implementation.

P&T committees routinely drive formulary changes and medication use management initiatives. The decisions P&T committees make often result in changes in clinical prescribing and practice as well, which can affect the care given to millions of patients.

Effective change agents need patience, energy, and leadership skills. They also must recognize that change may be slow and difficult. In a landmark article published in 1995, Harvard Business School Professor John Kotter reviewed the necessary factors for a successful transformation effort.

 In this first of 2 articles on the subject, I review Professor Kotter’s approach and apply some of his principles to a successful P&T committee process. In the next issue, I will provide an additional perspective on P&T committees and change.

Professor Kotter provides reasons why the transformation process may fail. I focus on the reverse: the ingredients in a successful P&T process. The following factors are important in leading change.

To lead effective formulary or medication use management changes, all P&T committees must establish a compelling sense of urgency, typically around issues of efficacy, quality or safety, or affordability. At its core, a P&T committee’s work is about creating more value for members’ premium dollars, while championing safe medication use and quality care. Frequently, that sense of urgency is communicated by the CEO and medical director. Their call for change in the face of rising healthcare costs and the worsening problem of the uninsured can help a P&T committee drive changes in prescribing.

A sense of urgency reinforces the importance of formulary management and medication safety. It promotes a committee’s work as essential to both the patient’s and the organization’s success, and creates an environment more conducive to successful transformation. Pharmaceutical and other healthcare manufacturers should begin their drug or technology research efforts with an understanding of the compelling needs that will drive P&T committee decision making and seek to develop products that can address those needs.

The composition of the P&T committee is critical. Because P&T committees drive changes in physician prescribing or changes in medication use, the credibility, reputation, influence, and “power” of the committee membership cannot be underestimated. As a P&T committee chair, I have always invited members not only because of their clinical skills and experience in evidence valuation, but also because of their reputations for excellence in the medical group. Taking the concept further, when I have encountered resistance to a medication management change or formulary withdrawal, I often have referred to my guiding coalition—my committee members&mdash;in leading the change. “Dr X and Dr Y are on the committee and are as concerned about this issue as I am.”

Clearly articulating the picture of a brighter future is fundamental to the work of a P&T committee. Explaining how a formulary change creates value for patients or creates savings that can be reinvested in other important ways to improve patient care is essential to effective change management.

The most powerful message formulary leaders can communicate is the vision of a safe and high-quality formulary that improves patient outcomes and avoids harm, as well as making healthcare more affordable. This message is becoming increasingly important as patients, employers, healthcare providers, and health plans look more closely at clinically appropriate therapies that may also have known risks. Citing the work of the Institute for Safe Medication Practices, a recent article identifies general steps being taken in the healthcare community to reduce the risk of harm.

 It mentions initiatives at specific hospitals to ensure appropriate use of some high-benefit, frequently used drugs that may cause harm if used incorrectly (eg, heparin, insulin, intravenous opiates, warfarin, methotrexate).

In my experience, this vision resonates strongly with medical group and pharmacy staffs. We all want to feel important and involved in work that contributes to a better tomorrow. We want to be able to assure our patients and employers that we are anticipating and preempting the possibility of untoward results in treatment.

Relentless communication with medical groups on the role of the P&T committee and the vision of affordable, safe, and effective pharmaceutical care is necessary to lead formulary and medication use management changes. This communication also is critical in helping physicians explain to patients—and plan management explain to employers&mdash;how the system is working at all times to achieve high-quality and cost-effective care.

Establishing the context for the change and naming the desired outcome are the work of both the P&T committee chair and the committee members. Making these expectations clear to committee members early on enables explicit discussions and member skill development, and amplifies the voice of the chair, often by a factor greater than 10. Clear and concise talking points that articulate the goals and direction of a P&T committee’s work—talking points that are reiterated through many channels of communication&mdash;are necessary to lead the kind of transformative change prescribers often are asked to undertake and patients and employers often are asked to accept.

Members of P&T committees all have been changed, lead change, and have a future filled with change. The work with regard to formulary and medication use management is in many ways about leading change in response to new information and creating a better tomorrow—for colleagues at work, colleagues in the larger prescribing communities, and most importantly, for patients. Understanding the factors necessary for successful change management will make this work more satisfying and rewarding, and make us more effective in the work ahead.