Shane P. Desselle, RPh, PhD, FAPhA

Pharmacy is rooted in entrepreneurship and has demonstrated a long history of innovation. There are a number of products you consume daily that were created by pharmacists. Large pharmaceutical companies and pharmacy wholesalers can often trace their roots to some innovative, determined, and hard-working pharmacists.

We read and hear much about practice change. By its very nature, practice change suggests it is borne from innovation, along with other factors. Change just for the sake of change is not necessarily positive, but the continued evolution from solely dispensing to more patient-centered practice has many benefactors. A study by Doucette et al examined the factors influencing practice change to more patient-centric and progressive styles.

The authors examined a number of factors. Adequacy of resources and pharmacy technician staffing were important. The most influential factors predicting successful practice change were 2 dimensions of the entrepreneurial orientation scale: proactiveness and autonomy. The results suggest that pharmacists who are proactive—in other words, taking account of the environment and being able to foresee health systems and patients’ needs ahead of time—are more effective in promoting practice change. Also important is when pharmacists appreciate working in an autonomous environment and, likewise, provide the empowerment and support for other pharmacists and staff to work with that same level of autonomy.

It is important to note that the study was undertaken in various types of ambulatory environments. One of the myths that surround the concept of entrepreneurism is that people are simply ‘born this way’. There are certain characteristics that predispose risk-taking and extroversion, but these 2 traits do not necessarily make for an effective entrepreneur. Moreover, entrepreneurism is something that can indeed be learned.

Pharmacy Management: Essentials for All Practice Settings, 5e

, Professor of Social/Behavioral Pharmacy at Touro University California in Vallejo.

Doucette WR, Nevins JC, Gaither C, et al. Organizational factors influencing pharmacy practice change. 

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Pharmacists who are proactive—in other words, taking account of the environment and being able to foresee health systems and patients’ needs ahead of time—are more effective in promoting practice change. 

Tip of the Week: Entrepreneurship Will Take You Far

Technology and technological breakthroughs abound. Some individuals use technology primarily to play games and share pictures of pets, while others use it to help solve complex problems that plague entire human populations. Health information technology is becoming available an accelerated pace, yet its uptake by end-users can be a bit slower. It might take more time to train individuals on how to effectively employ a new technology and convince them of its merit than engineers to develop the technology.

Investigators have described the training undertaken by pharmacists employed in a technology-based intervention study, in the 

International Journal of Pharmacy Practice

. The PINCER trial identified patients at risk from harm associated with pharmaceutical indicators such as patients with asthma being prescribed a beta-blocker, patients with peptic ulcer disease being prescribed a nonspecific nonsteroidal anti-inflammatory drug, patients on lithium therapy who require their levels be monitored every 3 months, patients on warfarin to have their international normalized ratios for blood clotting monitored every 12 weeks, and patients on oral contraceptives with a past history of venous or arterial thrombo-embolism.

Six pharmacists received 22 hours of training over 5 sessions. The training involved identification of these markers in patients, effective intervention strategies, and use of software tools to support the implementation of root cause analysis (RCA).

RCA is among the strategies recommended to promote medication safety by the Institute of Healthcare Improvement for advancing patient safety. It employs the use of a series of questions, graphics, and interconnected data to identify system vulnerabilities and implement strong actions that will mitigate or eliminate these vulnerabilities. It takes a systems perspective in the awareness that most quality problems or errors are not the result of an individual’s incompetence or malevolence but more likely attributable to system failures.

The pharmacists in this study who underwent the training reported a high level of satisfaction and greater confidence that they could identify and minimize existing errors, as well as potential errors by utilizing software that coincided with the objectives of the program.

Pharmacy managers must have the know-how and savvy to evaluate the cost-effectiveness of various technologies. Quite often, investment in such technology will reap its return many times over. However, vendor quality varies, and logistically there might be only so much space, capacity, capital, and time to invest in technologies. Any investment in technology must be accompanied by adequate training, buy-in, and a rational purpose that comports with the organization’s mission and scope. Of course, improving patient safety should be within the scope of every pharmacy organization.

Additional information about “Managing Technology that Supports the Medication Use Process and Preventing and Managing Medication Errors: The Pharmacist’s Role”can be foundin 

, professor of social/behavioral pharmacy at Touro University California in Vallejo.

Sadler S, Rodgers S, Howard R, Morris CJ, Avery AJ. Training pharmacists to delivery complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis. 

Health information technology is becoming available an accelerated pace, and it will take time to train individuals on how to effectively employ a new technology and convince them of its merit.

Tip of the Week: Avail Employees of Tools that Can Improve Patient Safety

Pharmacists are in position to be among the most important public health leaders. Substance use disorder has been a concern for decades, and the misuse of opioids has already exacerbated an enormous toll on the lives of Americans. This includes abuse of both illicit substances and prescription medications initially prescribed with benevolent intentions. The ability of pharmacists in the United States to dispense naloxone in many states could be a considerable help for this public health problem. However, uptake of pharmacists doing so is still far from maximized.

Investigators conducted a study to learn more about how pharmacists can support a sustainable approach to providing naloxone in the community, with results published in 

Research in Social and Administrative Pharmacy

.1 The authors describe factors currently known, or at least strongly suspected, to impact the uptake of pharmacy-based naloxone (PBN) dispensing, including number of full-time pharmacists at a location, adequacy of pharmacist training, and time constraints. Their study undertook interviews of pharmacy leaders to help better understand how pharmacy staff can optimize PBN.

Their interviews uncovered 5 themes, as follows:

 to mitigate hesitance in its dispensing and encourage staff to ask questions;

Strength through coordination of efforts:

 strengthening partnerships with hospital emergency departments, substance use disorder clinics, insurers, employers, and regulators;

: pharmacy as a profession and pharmacy organizations strengthen their organizational cultures to address this community health concern;

: ongoing attitudes that substance abusers to not “deserve” treatment; and

: inability to bill for services, and not having the right people positioned to receive patients presenting with substance use disorder.

The results of this study highlight the importance of pharmacy leadership and effective management. As the authors suggest, changes must be made at the staff, process, and organizational levels. Pharmacy managers and executive team members must examine their organizational philosophy to include a more public health-oriented mission. This includes paying more than just lip service to the problem; thus, training personnel, helping them seek proper continuing education and professional development, and positioning them in workflow operations so that health professionals can meet head on this, and other, public health problems. Needed organizational changes is another example of an unmet need for which pharmacy can stake a claim in its pursuit of better patient outcomes.

Additional information about Organizational Structure and Behavior and Value-Added Services as a Component of Enhancing Pharmacists’ Roles in Public Health in 

, Professor Social/Behavioral Pharmacy at Touro University California in Vallejo.

Donovan E, Bratberg J, Baird J, Burstein D, et al. Pharmacy leaders’ beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community. 

The ability of pharmacists in the United States to dispense naloxone in many states could be a considerable help for this public health problem. 

Tip of the Week: Using Effective Management to Combat Substance Use Disorder and Other Public Health Concerns

Pharmacy professionals have been highly responsive as frontline healthcare workers in response to the COVID-19 pandemic. Yet challenges remain in fully expanding pharmacists' ability to provide the best optimum patient care and overall population health interventions as well as ensure healthcare worker and public health safety. Pharmacy organizations have produced guidelines and advisories to guide workflow and optimize services during this pandemic, yet there still exists a gap in further integration of pharmacists into public health and safety initiatives.

Investigators have further sought to make further leaps in this area in development of the Pharmacy Emergency Preparedness and Response (PEPR) Framework.

Research and Social Administrative Pharmacy, 

the recommendations in this framework sought to fully integrate pharmacy professionals within public health emergency preparedness and response (EP&R) efforts, and emphasize to the public that pharmacists' roles, skills, and contributions merit recognition as integral members of the interprofessional health care team.

Through the influence of multiple pharmacy organizations' joint policy recommendations specifically geared in response to COVID-19, the PEPR Framework identified key focus areas to provide expanded guidelines for pharmacists across all practice settings. These areas include: emergency preparedness response; operations management; patient care and population health interventions; public health pharmacy; education and continuing professional education; and evaluation, research, and dissemination for impact and outcomes. Currently, pharmacists have contributed considerably towards improving public health through such examples as immunizations, health promotion, health education, medication counseling, and medication reconciliation.

Based on PEPR recommendations, pharmacy managers can assist greatly in affecting the significant impact that pharmacists can provide towards EP&R public health. They can take initiative and find ways to implement action plans from the proposed PEPR Framework. This merits their consideration as part of strategic planning by the pharmacy and subsequent incorporation of mission and core values that embrace the concept.

Adoption of these practices will invariably involve identifying and allocating resources toward these endeavors such as funding and personnel. Proper business planning and use of implementation science principles will help assure the sustainability of these services.

Pharmacy managers are encouraged to engage with key stakeholders such as other health care professionals, the business community, health plans, and local legislators. This will strengthen potential partnerships, market pharmacy as a profession, and increase the likelihood of acquiring reimbursement for these services.

Value-Added Services as a Component of Enhancing Pharmacists’ Role in Public Health 

Pharmacy Management: Essentials for All Practice Settings, 5e. 

is a PharmD candidate at Touro University California College of Pharmacy, Vallejo, CA.

, Professor of Social/behavioral pharmacy at Touro University California College of Pharmacy.

Aruru M, Truong HA, Clark S. Pharmacy Emergency Preparedness and Response (PEPR): A proposed framework for expanding pharmacy professionals' roles and contributions to emergency preparedness and response during the COVID-19 pandemic and beyond. 

Pharmacy organizations have produced advisories to guide workflow and optimize services, yet there still exists a gap in further integration of pharmacists into public health and safety initiatives.

Tip of the Week: Strategic Planning for Pharmacy Emergency Preparedness and Response Activities

Pharmacists face moral dilemmas every day in their practices. Role conflicts are inherent to the job, as we seek to simultaneously please supervisors, individual customers and patients, peers, other health professionals, regulators, and professional organizations.

Pharmacists must develop professional behavior and a common professional identity that goes beyond their personal values and self-interests. The professional values of pharmacists are critical to effective practice. Moral dilemmas arise when the wants or needs of 2 or more of the aforementioned parties are in contrast.

The authors of an analysis published in the 

International Journal of Pharmacy Practice 

examined the professional core values inherent to moral dilemmas faced by community pharmacists.

 During an ethics training course, students and pharmacists wrote about a moral dilemma they had experienced in practice, and they described their own ethical stances and values explicit in adjudication of those dilemmas. Examples of dilemmas included a patient presenting too early for a refill of pain medication and another with a patient overusing a laxative, with the pharmacist refusing to sell her additional doses, and yet another with a patient presenting with a legitimate refill prescription in spite of the drug doing her harm and masking a more serious condition.

The investigators coded the responses into 4 broad categories as follows:

Commitment to the patient’s well-being, but inclusive of the patient’s right to self-determination.

Pharmaceutical expertise, emanating from basic pharmaceutical sciences, therapeutics, and health psychology.

Reliability and care, thus developing trust and respecting the patient’s confidentiality.

Social responsibility, where the pharmacist is responsible for the societal implications of their actions and for guaranteeing access to and continuity for pharmaceutical care.

Previous studies have shown pharmacists to be caring but not necessarily operating on the same level of cognitive moral development as other health professionals. The management of medication therapy says much about doing the right thing in myriad situations even while holding consistently to a set of principal, core values. Every decision has consequences, and many decisions have negative consequences that might be outweighed by the greater good.

Pharmacy managers cannot be a part of each decision made by every employee; however, effective managers have carefully weighed the various mandates, policies, and societal influences to create an environment for—and even encourage&mdash;self-development and ethical decision-making training among all pharmacy personnel.

The “Management” in Medication Therapy Management 

can be found in Pharmacy Management: Essentials for All Practice Settings, 5e. 

, Professor of Social/Behavioral Pharmacy at Touro University California

Kruijtbosch M, Gottgens-Jansen W, Floor-Schreudering A. Moral dilemmas reflect professional core values of pharmacists in community pharmacy. 

Pharmacists must develop professional behavior and a common professional identity that goes beyond their personal values and self-interests.

Tip of the Week: Relying on Ethics to Lead the Way

Supervising employees and assuming leadership roles imply that you are taking accountability for the work productivity of others. If you are responsible for the work productivity of others, then it is in your best interest to provide them with the tools and resources they need to get the job done.

This might mean capital or physical resources, including equipment and appropriate staffing levels. It also means taking responsibility for the persons under your supervision to handle, even flourish, in the assigned tasks.

The right mix of skills and attitudes together form an employee’s self-efficacy beliefs, in which an individual acknowledges confidence in their ability to perform certain tasks.

Farrell et al examined whether the self-efficacy of pharmacists was enhanced following their participation in an online learning module.

 Specifically, the training aimed to help them incorporate the ADAPT (ADapting pharmacists’ skills and Approaches to maximize drug Therapy effectiveness) model into practice.

The program was designed to enhance pharmacists’ patient care and collaboration skills. The program included readings and exercises on teamwork and group dynamics, motivational interviewing, assertiveness, delineating tasks, prioritizing risks, pharmacoepidemiolgical principles, and effective delegation.

Surveys and interviews of ADAPT graduates saw their confidence rise in all aspects as a result of the program, including providing medication reviews, collaborating with other health professionals, interviewing patients, making evidence-based decisions, documenting care, and developing care plans. This resulted in an increase for those pharmacists in the number of billable services they provided and actual increases in reimbursement for billable services by pharmacists.

The online ADAPT program was demonstrated to be successful. Likewise, there are many such programs available to pharmacists, including but not limited to advanced medication therapy management training, immunization certification, and leadership courses.

Many of these are geared toward the working professional, or in other words, offered through online study or on weekends, or through self-direction. Pharmacy managers should not only take advantage of some of these offerings themselves, but offer access or even incentivize pharmacy staff to take part in self-development activities that can promote self-efficacy.

It might end up meaning success in diversifying the pharmacy’s revenue streams, but at the very least, it will result in improved competence and effectiveness of employees, along with a clear message to them that you are a supportive leader.

Additional information about Leadership and Organizational Structure and Behavior, and Implementing Value-Added Pharmacy Services

Farrell B, Archibald D, Pizzola L, et al. Impact on confidence and practice: How the ADAPT online patient care skills program made a difference for pharmacists. Res Social Adm Pharm. 2019;15(10):1251-1258.

Shane P. Desselle, RPh, PhD, FAPhA, professor of Social/Behavioral Pharmacy at Touro University California

Pharmacy managers should offer access and incentivize pharmacy staff to take part in self-development activities that can promote self-efficacy.
 