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					  PRACTICE RESEARCH


Designing success:
Workflow and design processes
that support pharmaceutical care
By John Ramaswamy-Krishnarajan, BPharm, MSc; David S. Hill, BSc(Pharm), MSc, MBA, EdD, FCSHP



P    harmaceutical care is a philosophy of the practice of
     pharmacy that has been accepted by many academic,
professional, and regulatory bodies as a foundation for pri-
                                                                                 community pharmacy practice sites that are engaged in
                                                                                 pharmaceutical care.

mary care by pharmacists in the health care system.1,2                           Background
Despite widespread acknowledgement of the importance                             As the profession pursues patient-focused pharmaceutical
of pharmaceutical care — or centering the pharmacist’s                           care standards, it is important that pharmacists be able to
role on the patient, rather than the drug — pharmacists                          assess the quality of the care they provide and recognize
have been slow to adopt it.3 Pharmacists may be more fre-                        any barriers to comprehensive care.14 Although several
quently engaged in passive pharmaceutical care activities,                       pharmaceutical care models and practice guidelines have
such as information-gathering and acting as a drug-infor-                        been proposed and developed for community pharmacy
mation source, than in active interventions, such as patient                     settings,2 minimal work has been done on evaluating the
counselling and drug monitoring, according to Schommer                           specific design features and workflow processes associated
and Cable.4 Also, it has been observed that many pharma-                         with the provision of pharmaceutical care.
cists still perform highly distributive functions, with very lit-                    Despite the challenges, many Canadian pharmacists
tle commitment to pharmaceutical care responsibilities.5,6                       have overcome barriers to the provision of pharmaceutical
    Traditional pharmacy design characteristics and admin-                       care, altering both the arrangement of pharmacy resources
istrative constraints may be reasons for the inertia in pro-                     and the activities performed by the pharmacists.
viding pharmaceutical care as part of routine pharmacy                           Pharmacists across Canada can learn from their colleagues’
practice.7,8 Many obstacles to the provision of pharmaceu-                       experiences and successes in these community pharmacy
tical care have been discussed in the literature, including                      sites.
barriers in:
• Infrastructure (physical layout, staffing levels, excessive                    Results
workload, time constraints)                                                      Respondent summary: The response rate from 261 queries
• Cognitive skills (lack of competence, inadequate training)                     was 62%, with 162 usable responses (Table 1). A major
• Communication (lack of motivation, skills, or support)                         proportion (about 83%) of the respondents were from
• Compensation (economic incentives to provide pharma-                           independent pharmacies. Further, 72% of the pharmacies
ceutical care)                                                                   were from urban locations, and 28% were in a rural set-
• Logistics (lack of access to patient medical information                       ting. Forty-four pharmacies were placed in the highest
and to other health care professionals)                                          quartile subgroup, and 45 pharmacies were assigned to the
• Motivation and training (unwillingness to take full ad-                        lowest quartile subgroup.
vantage of technological developments)7,9-13
    The objective of this study was to examine the design
and workflow characteristics across a sample of Canadian                                                                                  Cont’d on p. 40




➧ More on pharmaceutical care coming in May
At the time this research was conducted, John Ramaswamy-Krishnarajan was an MSc student in the Faculty of Pharmaceutical Sciences at the
University of British Columbia, Vancouver. Dr. Hill is the Associate Dean for Administration and Clinical Affairs in the School of Pharmacy at the University
of Colorado at Denver and Health Sciences Center. When this research was conducted, he was Associate Dean for Clinical Programs in the Faculty
of Pharmaceutical Sciences at UBC. Address correspondence to John Ramaswamy-Krishnarajan, 2347 Summercreek Drive, # 95, Santa Rosa, CA, 95404;
e-mail: krishnarajan@sbcglobal.net.


CPJ/RPC • APRIL 2005, VOL. 138, NO. 3                                                                                                                    39
Designing success . . .              Cont’d from p. 39

Performance on Behavioral Pharmaceutical Care Scale:
The mean Behavioral Pharmaceutical Care Scale (BPCS)
                                                                     FIGURE 1 — Behavioral Pharmaceutical Care Score
score of all respondents was 110 (range 39-171, SD 28.6).                       distribution
The 25th-percentile score was 93, and the 75th-percentile
score was 130.2. A histogram displaying a normal distribu-
tion of the BPCS scores (as determined by a Lillefor’s test                         30

for normality) is presented in Figure 1.
Subgroup comparison: Regarding time allocation, a higher
percentage of highest-quartile subgroup pharmacies
reported allocation of more hours for pharmaceutical care                           20




                                                                        Frequency
activities than those in the lowest-quartile subgroup. In the
highest-quartile subgroup, 50% of the pharmacies allo-                                                                                                                 Mean = 110.9
                                                                                                                                                                       SD = 28.61
cated four to seven hours per day, whereas only 19.6% of                                                                                                               Range = 39–171
                                                                                    10                                                                                 N = 162




TABLE 1 — Demographic characteristics of respondents
                                                                                     0
                                                                                         40        60        80        100         120         140         160
Respondent summary                 Study Group
                                                                                              50        70        90         110         130         150         170
Response rate                                                                                                 BPCS scores
   Questionnaires sent             261
   Questionnaires received         162
   Response rate                   62%
                                                                     the lowest-quartile subgroup pharmacies allocated a simi-
Ownership category                                                   lar number of hours for pharmaceutical care activities.
  Independent (other)              105 (64.8%)                          The highest-quartile subgroup reported a significantly
  Independent (banner)             29 (17.9%)                        higher allocation of hours per day specifically for pharma-
  Drugstore chain                  26 (16.0%)                        ceutical care activities than the lowest-quartile subgroup,
  Mass-merchandiser chain          2 (1.2%)
  Grocery-store chain              0
                                                                     as determined by Pearson’s chi-square test (p < 0.01)
                                                                     (Table 2).



                                                                   METHODS

  A data collection instrument, the Community Pharmacy Structural Elements Questionnaire (CPSEQ), was developed based on
  information obtained from a literature search of articles reporting structural changes in community pharmacy practices. In a
  pretest of 28 community pharmacy sites, the CPSEQ was found to have reliability and validity as an instrument for gathering
  information about the following categories of structural elements in community pharmacy:
  • Reorganization of pharmacists’ and pharmacy technicians’        • Direct patient care
    duties                                                          • Referral/consultation
  • Changes in physical layout                                      • Pharmaceutical care instrumental activities
  • Training for pharmacists and pharmacy technicians                   When completing the BPCS, respondents are asked to
  • Financial compensation                                          reflect on their interaction with the five most recent patients
  • Modification of store policies and procedures                   who have presented with prescriptions to treat a chronic
  • Incorporation of technology                                     condition. The respondents then indicate how many of the
     Respondents were assigned scores on the CPSEQ based            five patients received the listed pharmaceutical care activi-
  on their reporting of recent structural changes; each change      ties. Possible responses range from 0 (none of the patients)
  was given an equivalent score of one, and the scores were         to 5 (all five patients) for each domain item. The theoretical
  summed to determine a total score for the pharmacy.               total score on the BPCS, therefore, can vary from a low of 16
                                                                    to a high of 180.
  Behavioral Pharmaceutical Care Scale: Our data collection
  instrument also included the Behavioral Pharmaceutical Care       Selection of respondents
  Scale (BPCS) developed by Odedina and Segal.15 It is a multi-     Study group participants were selected from community
  item scale that measures pharmacists' efforts toward providing    pharmacy practices across Canada. They were selected
  pharmaceutical care. The scale comprises 34 behavioural activ-    based on their affiliation with any one of six pre-identified
  ities representing the following pharmaceutical care domains:     pharmaceutical care models, or with the structured practice


40                                                                                                                     CPJ/RPC • APRIL 2005, VOL. 138, NO. 3
                                                                                                  KEY POINTS
TABLE 2 — Time allotted for pharmaceutical care activities
                                                                           • Since its introduction in 1990, “pharmaceutical care”
Number of hours specifically   Lowest-quartile     Highest-quartile
                                                                             has become a key conceptual framework for developing
allocated for pharmaceutical   subgroup (n = 45)   subgroup (n = 44)
care activities
                                                                             community and hospital pharmacists’ roles.
                                                                           • Pharmaceutical care is patient-centered rather than
Number of hours per day
                                                                             product-centered.
  0–3                   78.3%                      37.5%
  4–7                   19.6%                      50%
                                                                           • Pharmaceutical care is an important precursor to phar-
  8 and above           2.2%                       12.5%                     macist involvement in primary health care.
                                                                           • Despite widespread support of the concept by profes-
Pearson’s chi-square test
                                                                             sional leaders, individual pharmacists have been slow to
   Statistic                   15.1
   Degrees of freedom          2
                                                                             adopt it.
   p-value                     < 0.01                                      • Barriers include an actual lack of expertise to make drug
                                                                             therapy decisions.
                                                                           • Structural changes in community pharmacies are
   Regarding structural elements, the frequencies of                         necessary to implement the pharmaceutical care model.
specific design or workflow elements reported were com-
pared using Pearson’s chi-square test. Structural elements
that were reported in a significantly higher frequency by                toward the provision of pharmaceutical care (based on the
the highest-quartile subgroup were decreased pharmacist                  Behavioral Pharmaceutical Care Scale). The unexpected
involvement in technical dispensing functions, use                       finding of some very low BPCS scores suggests that,
of audiovisual educational equipment, and the require-                   despite a stated affiliation with a defined pharmaceutical
ment for sit-down counselling for new prescriptions (all                 practice model, there were respondents who could
p < 0.01). Practice-site changes, such as increased phar-                demonstrate little evidence of positive patient care efforts
macist involvement in provision of professional services                 as measured by the BPCS.
and a change in the dispensary software system, were also                Time: The exploratory analysis revealed that in the reorga-
reported with high frequency by both subgroups, but were                 nization of pharmacists’ duties, decreased pharmacist
not statistically different (Table 3).                                   involvement in technical dispensing functions was
                                                                         reported with a higher frequency by the highest-quartile
Discussion
Many practice leaders demonstrated significant progress                                                                  Cont’d on p. 43



                                                               METHODS

  experiential teaching programs known to be in place in                 responses. A survey package, which included the CPSEQ, the
  Canada at the time the survey was conducted:                           BPCS, a cover letter, and a self-addressed postage-paid
  • Health Outcomes Pharmacies                                           envelope, was then mailed to 261 potential respondents
  • Structured Practical Experience Program (University of               who consented to participate in the survey. The survey
    Toronto)                                                             administration took place from August 27, 1999, to
  • Clinical Associate Program (University of Montreal)                  November 22, 1999.
  • Asthma Self-Management Education Program (British
    Columbia)                                                            Analysis
  • Geriatric Pharmaceutical Care Model (Manitoba)                       Using the distribution of total scores from the BPCS, the
  • Pharmaceutical Care Research and Education Program                   highest-quartile (HQ) subgroup (respondents above the
    (Alberta)                                                            75th percentile) and lowest-quartile (LQ) subgroup (respon-
  • Pharmaceutical Care Model (Dalhousie)                                dents below the 25th percentile) were determined. The HQ
  • In-Home Drug Evaluation Model (Saskatchewan)2                        subgroup represented respondents with evidence of signifi-
     A total of 301 community pharmacy practices in Canada               cant progress toward providing pharmaceutical care. The
  were estimated to be affiliated with at least one of these             LQ subgroup represented respondents who, in the assess-
  pharmaceutical care models or programs.                                ment of the researchers, could provide little validation of
                                                                         progress toward pharmaceutical care, despite their affiliation
  Survey administration                                                  with a model or program.
  Potential participants were contacted by telephone by                     Exploratory analysis was conducted to compare the
  a member of the research team and were invited to partici-             design and workflow elements and the hours per day allo-
  pate following a brief explanation of the study. The resear-           cated for pharmaceutical care activities reported in the
  chers assured participants of the confidentiality of their             CPSEQ by the HQ and LQ subgroups.


CPJ/RPC • APRIL 2005, VOL. 138, NO. 3                                                                                                 41
TABLE 3 — Key elements in the lowest-and highest-quartile subgroups

                                                                Lowest-quartile     Highest-quartile
                Design and workflow elements                                                                  p-value
                                                                subgroup (n = 45)   subgroup (n = 44)


Reorganization of pharmacists’ duties

Decreased pharmacist involvement in technical functions         51.1%               90.9%                     < 0.01


Increased pharmacist involvement in provision of profes-        91.9%               95.5%                     0.41
sional services

Reorganization of pharmacy technicians’ duties

Increased pharmacy technician involvement in technical          71.1%               84.1%                     0.14
functions

Changes to physical layout

Incorporation of unelevated pharmacist workstation              35.6%               63.6%                     < 0.01


Creation of layout accommodating the needs of                   22.2%               56.8%                     < 0.01
the disabled
Incorporation of a patient waiting area                         48.9%               75%                       0.01


Incorporation of a private patient counselling room             64.4%               77.3%                     0.18


Incorporation of a semi-private patient counselling area        62.2%               65.9%                     0.71


Incorporation of audiovisual educational equipment              37.8%               68.2%                     < 0.01


Incorporation of educational materials                          73.3%               95.5%                     < 0.01


Pharmacist training

Formal training program                                         77.8%               86.4%                     0.29


Pharmacy technician retraining

On-the-job training                                             53.3%               65.9%                     0.22


Financial compensation

Payment by third-party payers                                   6.7%                27.3%                     < 0.01


Modification of store policy and procedure

Requirement for sit-down counselling for all new and            11.1%               35.4%                     < 0.01
refill prescriptions

Technological changes

Change in pharmacy software                                     57.8%               65.9%                     0.43


Incorporation of hardware/software systems that answer          2.2%                11.4%                     0.08
pharmacy phones
Incorporation of automatic pill counters                        20%                 29.5%                     0.29


CI = confidence interval; NRT = nicotine replacement therapy.



42                                                                                                 CPJ/RPC • APRIL 2005, VOL. 138, NO. 3
Designing success . . .                 Cont’d from p. 41

subgroup than the lowest-quartile subgroup (p < 0.01).
This is an important change associated with the provision          Barriers to pharmaceutical care
of pharmaceutical care, since pharmacists must free up
                                                                   • Weak communication skills
time to focus on patients’ medication-related problems.
Physical layout: The presence of an unelevated pharmacist          • Inability to select appropriate patient educational tools
workstation, the design of a patient waiting area, the use
                                                                   • Inability to recognize situations in which specific knowl-
of audiovisual educational equipment, and the incorpora-
tion of patient-education materials were all reported more            edge is necessary
frequently by the highest-quartile subgroup (p < 0.01).            • Inability to select and apply scientific technical and clini-
    Since the design of a separate counselling area was a
precondition of participation or enrolment in many of the             cal information in a timely and appropriate manner
pharmaceutical care models or programs, both subgroups             • Lack of expertise to make drug therapy decisions
were expected to score high with respect to this require-
ment. These design features are seen to be beneficial in
facilitating patient contact, increasing privacy for confiden-   No time implications: The survey asked respondents to
tial conversations, enhancing the patient counselling envi-      simply indicate the changes that had been made in the
ronment, and adding resources that complement and                pharmacy to implement a pharmaceutical care practice. No
reinforce patient counselling. The benefits of these             supplemental information was requested to determine the
changes to the physical layout of the pharmacy in over-          timing of any structural changes or to assess whether or
coming barriers such as workspace, resources, and time to        not the changes were part of a deliberate pharmaceutical
enhance the provision of pharmaceutical care, have also          care strategy. Future research that uses a longitudinal
been widely discussed in the literature.7,11,14,16,17            design would permit study of the timing effect on selected
    Both subgroups were expected to score high in the            variables and the pharmacist’s motivation to make
pharmacists’ training category, as this was also a manda-        changes.
tory requirement of several of the pharmaceutical care
models and programs. Pharmacists and pharmacy techni-            Conclusion
cians may require additional training to overcome identi-        Building a successful pharmaceutical care practice is not a
fied barriers (see box).                                         simple task. Established community pharmacy sites in
    In the modification of a pharmacy’s policy and proce-        Canada with successful pharmaceutical care practices are
dures category, the requirement for sit-down counselling         still few in number. This remains uncharted territory with-
for all prescriptions was reported with higher frequency in      out proven models from which pharmacists can plan
the highest-quartile subgroup. This procedural change            design and workflow changes. Affiliation with a pharma-
may help ensure that comprehensive care is provided,             ceutical care model or program such as those followed in
including monitoring, continuity of care, and follow-up.         this study could be a useful strategy for facilitating practice
    This subgroup consisted of progressive community             change.
pharmacy practices and provided more evidence indicative             This study characterizes the efforts that have been made
of progress toward the provision of pharmaceutical care          by some innovative Canadian community pharmacy prac-
than the lowest-quartile subgroup. The results of the            tices to provide pharmaceutical care. This preliminary list-
exploratory analysis revealed that the highest-quartile sub-     ing of design and workflow elements may be a useful
group pharmacies allocated more hours per day specifi-           resource for assisting community pharmacists to translate
cally for pharmaceutical care activities. These community        the philosophy of pharmaceutical care into daily practice.
pharmacy practices also made design and workflow                 Further, the findings reported here are intended to gener-
changes to facilitate their pharmaceutical care practice         ate guidance for the development of future research stud-
objectives.                                                      ies to provide stronger evidence about pharmacy structural
                                                                 changes that support the provision of pharmaceutical care
Limitations of study                                             in the community pharmacy. ■
Self-reporting bias: The information for this study was gath-
ered through a survey using instruments (the CPSEQ and
the BPCS scales) that required self-reporting by pharma-         Acknowledgements: We would like to express our gratitude to Apotex
cists. Therefore, there was opportunity for respondents to       Inc. for its generous research grant, which funded this study. We also
modify or falsify answers in order to appear better at pro-      express our sincere appreciation and thanks to Dr. Timothy-John Grainger-
                                                                 Rousseau, who initiated this study, for his most significant and valuable
viding pharmaceutical care (i.e., social-desirability bias).
                                                                 input throughout the research project.
To help control for this behaviour, respondents were
assured of total anonymity, as well as of the confidential-
ity of their responses.                                                                                            References on p. 44



CPJ/RPC • APRIL 2005, VOL. 138, NO. 3                                                                                                 43
Designing success . . .                    Cont’d from p. 43

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