Establishing a clinical pharmacy department

To provide higher quality clinical pharmacy services at a tertiary health centre, a clinical pharmacy department, based on a theoretical model, was formally established and organisational changes were feasible and financially justified.

Clinical pharmacists are seen as a ‘primary source of scientifically valid information and advice regarding the safe, appropriate and cost effective use of medications’.¹ By offering regular consultations, evaluations and recommendations to patients and healthcare professionals, pharmacists optimise use of medicinal products and devices, promote health, wellness, and disease prevention.^1,2

Common clinical pharmacy services (CPSs) relate to drug history (DH) taking and medication reconciliation (MR) on admission, making necessary adjustments of therapies – pharmacist interventions (PIs) during hospital stay and taking part in discharge management of the patients – patient counselling and follow-up.³

Although it is difficult to put a monetary value on CPSs, financial benefits come both through cost savings and cost avoidance. Cost savings can be measured by comparing medication costs of the physicians’ prescribing patterns with the actual costs of treatment (which can directly be reduced with PIs). Furthermore, costs can be indirectly avoided by optimising pharmacotherapy, reducing medication errors, reducing preventable adverse drug events and increasing patients’ adherence.^4–8

CPSs have already been introduced to certain extent in several Slovenian hospitals, including the University Medical Centre Ljubljana (UMCL) – the largest national healthcare institution. Structured into clinical departments or wards (CDs), UMCL covers all main clinical areas except adult psychiatry and provides services at the secondary and tertiary level.

UMCL pharmacy department has gradually started introducing CPSs for inpatients on certain CDs in 2010, using a pharmacy-based, “one pharmacist, one CD” approach.

However, CPSs have not been distributed equally. Furthermore, the roles of pharmacists on CDs have initially been defined very broadly, which has led to different approaches and different types of the services provided, depending both on the needs of the CD and on the personal judgement/decision of the pharmacist. Therefore, they have not been used to their full potential and their benefits have remained underestimated. A plan for improving CPSs at the UMCL deemed necessary.

Methods

A theoretical model of formal establishment of a Clinical Pharmacy Department (tCPD) as a part of UMCL Pharmacy was set up.

tCPD model included:

• Structural and organisational changes.
• Financial plan with the break-even analysis based on estimated costs and direct cost savings.
• Marketing plan with a stakeholder analysis.
• Quality assurance plan and assessment, with suggested key performance indicators.

Based on the proposed tCPD, an actual clinical pharmacy department (CPD) was created as a new unit of the UMCL pharmacy department. After successful realisation, the benefits of the actual CPD were estimated by comparing the number of tasks/information successfully completed/provided by clinical pharmacists on the CDs.

Results

• Structure and organisation

In tCPD, suggested roles of clinical pharmacists have been defined either as daily, weekly, or long-term tasks (Table 1).

A senior clinical pharmacist was anticipated to be employed full-time as a ‘Quality and Clinical Pharmacy Manager’ (QCPM) to take over the management of the CPD, which included planning, organising, and directing clinical pharmacy programmes, as well as monitoring and providing quality assurance of CPSs.⁹ New facilities and additional technological support were planned. Training and education were included in the form of an existing three-year clinical pharmacy specialisation programme, and continuous (life-long) learning by regular participation in educational events.

Full time equivalents (FTEs) for clinical pharmacists have been suggested, according to the number of admitted patients per working day for each CD, on assumption that one pharmacist, dedicating 40% of the working time to clinical work (0.4 FTEs), is sufficient for the provision of optimised CPSs for five newly admitted patients per working day (Table 2).

A CPD, based at the UMCL pharmacy department, was formally established, with:

• Expansion of clinical pharmacy staff (increase from 9–16 pharmacists from 2010–2013);
• Higher level of organisation (increased management team; regular weekly meetings, presentations of clinical cases);
• New, additional location for clinical pharmacy work;
• Stronger information technology support;
• Provision of additional training and education (three pharmacists newly specialised; ten pharmacists undergoing specialisation programme; continuous education in process).

With the implementation of CPD, certain structural and organisational changes were realised. The upward trend in CPSs has been demonstrated, particularly on the paediatric CDs (Table 2). However, CPSs remained far from being equally distributed and were still not performed continuously (and not on all the CDs).

Major improvements since 2011 were seen in the provision of long-term tasks, such as sharing relevant drug information with healthcare staff, critically assessing new information, and actively participating in professional events. Optimisation of daily tasks, apart from regular attendances on ward rounds, was less successful, mainly due to failure of required redistribution of pharmacists on CDs, which happened for multiple reasons: from increased workload of pharmacists at the UMCL Pharmacy and prioritisation of processes at the other pharmacy units, to resistance to change on various levels. Majority of clinical pharmacists were not provided regular time for clinical work, making it difficult to continuously provide CPSs. In tCPD, all pharmacists were planned to master two clinical areas (the second one in order to facilitate continuity of care on each CD), which has not yet been put into practice.

As there was no possibility for employing a senior clinical pharmacist in practice, the Head of the UMCL pharmacy department (with the assistance of a junior clinical pharmacist) took over the role of the QCPM.

The overall number of tasks/information successfully completed/provided by clinical pharmacists on the wards increased from 3856 to 9059 from 2011–2013 (comparing periods January to September 2011 versus 2013, respectively).

• Financial plan

The main costs, predicted in tCPD, included new equipment and technological support, education and training and pharmacists’ salaries. Net cost savings from the optimisation of therapy have been estimated, according to the literature data, to be €40 per patient on average.8 For further financial estimates in tCPD, two key assumptions were made regarding the provision of CPSs:

1. Practical skills of clinical pharmacists on initiation are lower than optimal;
2. PIs’ acceptance by physicians is less than 100%.

Both parameters were estimated at 50% for the starting year. Together, they were termed as a “pharmacists’ overall efficiency factor”, initially set up at 0.25 (25%) and predicted to gradually improve in the following years (every year by 5%). This factor has been identified as the key parameter for the accuracy of the break-even analysis.

Therefore, yearly direct cost savings from additional CPSs were estimated to be approximately €300,000 for the starting year (calculated as 0.25 *9.1 FTEs/0.4 FTEs *five patients *five days *52 weeks *€40) and the start up costs were assessed to be repaid in 23 months (break-even point in Figure 1). An evaluation of financial benefits after actually implementing CPD has not yet taken place.

• Marketing plan

Appropriate marketing strategy was seen as essential for the establishment and future development of CPD, since the political will to expand CPSs in times of economic instability was (and still remains) unsatisfactory, and the increased workload of pharmacists a relevant issue. A number of different stakeholders were considered relevant for the promotion of CPD. The UMCL Board of Directors, Heads of CDs, senior doctors and nurses and clinical pharmacists were recognised as the groups both with high influence and of high importance. Patients and their families were seen as highly important (although with less direct influence), whereas professional authorities, government bodies and broader pharmacy staff were seen as highly influential (but of lower importance).

The marketing strategy suggested financial emphasis for the UMCL Board of Directors, focus on the clinical outcomes for CD staff, and fusion of individual and organisational values for the UMCL pharmacy staff.

• Quality assurance

Several performance indicators were suggested in the Quality Assurance plan for tCPD (Table 3).

The QCPM was anticipated to take responsibility for quality assurance processes at three levels – structure, processes and outcomes, with the emphasis on health-related outcomes. However, the entire Clinical Pharmacy Department staff were included to participate in registering activities to allow for appropriate assessment of the performance indicators.

Thus far, documentation keeping has been addressed and complete protection of patient data has taken place, facilities to enable appropriate working conditions have been provided, whereas clinical work of individual pharmacists and prioritisation of tasks are currently under assessment. All the clinical activities, including PIs and reported adverse drug events are registered electronically. Clinical pharmacists are becoming increasingly engaged in terms of active participations at professional local and international events, with more publications in peer-reviewed journals every year. We have not yet been able to assess the quality of CPSs by direct measurement of health or financial outcomes. There are new electronic solutions for CPSs currently under development, to facilitate improved exchange of professional information between clinical pharmacists, to ensure all the electronic patient information analysed is fully protected, and to ease both the process of registering clinical pharmacy activities as well as future evaluations of working activities.

Conclusions

This report shows that establishment of CPD is a feasible and, most likely, financially justified project. However, in the case of the CPD at UMCL, several issues still have to be addressed before the complete implementation of the desired changes. Pharmacists’ knowledge and skills can only be increased with regular, continuous clinical work in practice. Improved tools to assess the CPSs, directly measuring health and financial outcomes rather than processes, are necessary to fully demonstrate their benefits. To provide equal distribution of CPSs and continuity of care on CDs, further reorganisation and more clinical pharmacy staff will be necessary, with every clinical pharmacist mastering two clinical areas, and with a potential shift of less demanding tasks to pharmacy technicians. Careful future planning and gradual introduction of new services is required to develop CPD and related activities to their full potential. In the future, we strive for high-quality CPSs, performed at the level of UMCL, with continuity of care provided for every patient on every clinical ward.

Key points

• Common clinical pharmacy services include medication reconciliation on hospital admission, necessary pharmacotherapeutic interventions during hospital stay and patient counselling before discharge.
• To successfully establish a clinical pharmacy department, structure and organisation, financial and marketing strategy and quality assurance should be planned thoroughly.
• It is difficult to put a monetary value on clinical pharmacy services. However, financial benefits come both directly, as cost savings, as well indirectly, as cost avoidance.
• Practical skills of clinical pharmacists and acceptance of pharmacist interventions on clinical departments are essential for successful implementation of clinical pharmacy services.
• Hospital Board of Directors, Heads of clinical departments, senior physicians and nurses are key stakeholders when making a marketing strategy for the promotion of clinical pharmacy services.

Authors

Matej Verbic MSc Pharm
Clinical Pharmacist
University Medical Centre Ljubljana, Slovenia

Andreja Cufar MSc Pharm
Head of Pharmacy
University Medical Centre Ljubljana, Slovenia

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