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Delivery of clinical pharmacy services with a flexible workforce

Abstract

Aims

The clinical pharmacy services leads at Manchester University NHS Foundation Trust (Wythenshawe site) have designed and implemented a service delivery model utilising a pharmacy digital tracker board and workforce management system that allocates staff based on patient risk and workload. The aim of this paper is to describe the flexible service model and examine outcome measures pre- and post-implementation.

 

Methods and results

A bespoke digital pharmacy tracker board was implemented from January to March 2017 alongside a senior pharmacist ‘Clinical Coordinator’ role to monitor workload and reassign staff accordingly. Following implementation of the new service delivery model, we recorded a significant increase (p=0.001) in the number of patients with medicines reconciliation completed within 48 hours of admission, a 29% increase in the number of discharge prescriptions dispensed within two hours and a reduction in incident reports relating to failure to deliver pharmaceutical care as per local standards from four to zero. A staff satisfaction survey supported the change in practice, with staff reporting that it supported them in their role and they felt strongly that it should continue.

 

Conclusion

The introduction of a flexible service module has demonstrated benefits both to patients and staff (in terms of improved service delivery for patients and increased support for pharmacy teams when needed) by efficient and effective use of our workforce. 

 
Wythenshawe Hospital, part of Manchester University NHS Foundation Trust (MFT) in the UK, is a major acute teaching hospital, providing a number of specialist tertiary services. Clinical pharmacy services are provided to the wards by directorate specific teams of pharmacists and pharmacy technicians. Clinical pharmacy services are delivered in line with our departmental clinical pharmacy standards. These standards dictate that patients should be assigned a pharmaceutical acuity level and that the frequency of pharmaceutical review is targeted based on acuity. The use of a system to identify patients most in need of pharmaceutical care is supported both in the literature and in the Royal Pharmaceutical Society, Professional Standards for Hospital Pharmacy Services.1-4
 
We have noted a high variability of workload between the directorate pharmacy teams throughout the working day or week. The unpredictability of where, when and how much our pharmacy services are required results in occasions where workload either exceeds or under-utilises the capacity of the staff assigned to a ward and has the potential to impact on the consistency of the quality of care we are able to provide as well as affecting staff well being and morale. In view of this, the clinical services leads developed a model of service delivery that moves staff from a previously rigid ward assignment rota system to a dynamic workforce that is proactively flexible based on the peaks and troughs in the workload demands across wards. The aim of this paper is to describe this flexible service model and examine outcome measures pre- and post-implementation.
 

Method

To achieve our aim we needed a way to monitor workload in ‘real time’. The introduction of an Electronic Patient Record (EPR) at the Wythenshawe site offered a digital solution to this problem and a bespoke digital pharmacy tracker board was developed that captures the pharmacy workload on each ward. The tracker board is illustrated in Figure 1.
 
Figure 1: Electronic Patient Record (EPR)
Figure 1: Electronic Patient Record (EPR)
 
The EPR system used at the Wythenshawe site of MFT uses an electronic patient status board (tracker board) providing at-a-glance clinical information to allow healthcare professionals to track activity and prioritise workload. The pharmacy view function of the tracker board is used by pharmacy teams to assign or update the patient’s pharmaceutical acuity level, to log when a patient has had a pharmacy review, completed a check of patients’ own drugs (POD)/in-patient medication supply or has dispensed a discharge prescription. There is also the ability to add or amend comments.
 
Patients are classified on the tracker board by pharmaceutical acuity level thereby facilitating the prioritisation of patients. Previously at the Wythenshawe site of MFT a service evaluation project was conducted to design a pharmaceutical assessment screening tool (PAST) to assign all inpatients a patient acuity level (PAL).2 The PAST offers guidance to pharmacists on how to allocate pharmaceutical acuity to patients, whereby the most pharmaceutically complex patients at greatest risk of developing adverse drug reactions are assigned a PAL score of 3 and the least complex receive a score of 1.
 
The tracker board records and reports key performance indicator (KPI) data (such as the timeliness of performing medicines reconciliation (MR) for each patient) thereby supporting performance management. From January to March 2017, following production of standard operating procedures (SOP), and a period of staff training we implemented the pharmacy tracker boards.
 
To manage the daily service a clinical co-ordinator role was initiated and developed utilising senior pharmacists. This role involved monitoring the workload intelligence throughout the day and allocating staff to wards or locations accordingly. The Clinical Coordinator role is supported by aSOP and the departmental clinical standards, which set out the minimum standards for service delivery.
 
To assess the impact of the new model of service delivery on our productivity we analysed the percentage of MR (performed within 48 hours of admission as per our locally agreed KPI) over time using an interrupted time series analysis with a segmented regression to identify the different trends before, during and after the implementation of the tracker board and Clinical Coordinator.
 
The new model of service delivery required a significant culture change within the pharmacy department and therefore regular staff engagement sessions were held to ensure all staff understood the purpose, benefits and risks of the change and also to receive feedback from the staff and adapt processes where necessary. 
 
To assess our workforce’s views on the changes implemented we developed an online survey for the pharmacy department staff to complete. The survey utilised a Likert scale (a scale used to represent people’s attitudes to a topic) with 10 being most satisfied and 1 not satisfied at all. Results of the survey were presented as an average score.
 
The pharmacy department periodically conducts an audit to assess the time taken to dispense discharge prescriptions. Data collected prior to and post implementation of the new service delivery model was compared to see what impact our changes have had on patient flow.
 
The impact of our service model on patient safety has been assessed by reviewing incident reports logged in the year prior to implementation of the tracker boards and reports logged in the year post implementation. 
 

Results

We have recorded an increase in the percentage of patients for whom MR is performed within 48 hours of admission as illustrated in Figure 2.
 
Figure 2
 
The intervention began with the introduction of the tracker board from January to March of 2017, including an education programme with the pharmacists on how to use the tracker board and the development and implementation of the Clinical Coordinator (March to April 2017). The Clinical Coordinator is fully developed and imbedded in practice from May 2017 onwards.
 
In Figure 2, three distinct phases are observed. These are April 2016 to December 2016; before the implementation. There is a low (76.9%) proportion of MRs performed and small change in the downward trend of MRs (-8.9% per month) over this time period. During the implementation phase of the tracker board and the instalment of the Clinical Coordinator, the percentage of MRs increased from 77.9% in January 2017 to 83.1% in April 2017, when the implementation phase ended. During the implementation phase, the number of MRs increased by 2.1% per month. Following the implementation phase, the percentage of MRs conducted stayed fairly stable with an average of 88.0% but slowly increasing over time; 0.9% each month. There was a significant change in average trends of MRs in the before phase compared with the after phase (p=0.001). 
 
Comparison of the average time to process and dispense discharge medication also shows improvement with the percentage of discharge prescriptions dispensed within two hours increasing from 61% in 2014 to 90% in 2017 (Figure 3). However, it should be noted that during the time period of 2014 to 2017, the pharmacy department outsourced their outpatient dispensing (thereby creating some additional capacity with dispensing staff) which will have also had a positive impact on dispensing times for discharge prescriptions In terms of patient safety, in the 12 months prior to implementation, four incidents had been reported as a direct result of failures to provide clinical services in line with our departmental clinical standards. In the 12 months post implementation, there have been no incident reports of this nature.
 
Figure 3
 
A response rate of 21% was recorded for the staff survey (Figure 4). The results of the survey suggested that staff strongly favoured continuation of new system of work (7.23 weighted average, 0–10 scale) and reported it supports staff in their role (6.4 weighted average, 0–10 scale).
 
Figure 4
 
Daily assessment of the tracker board coupled with results from our audits of compliance with departmental clinical pharmacy standards have demonstrated that the pharmacy tracker boards and Clinical Coordinator role have been successfully implemented into practice.
 

Discussion

Creating a dynamic workforce that maximises efficiency whilst ensuring quality is a key component of the trusts Hospital Pharmacy Transformation Plan (as per the Carter report5).
 
Within the literature reviews for the update of the hospital pharmacy standards, the Royal Pharmaceutical Society acknowledges that digital developments will provide further opportunities to prioritise clinical pharmacy care to patients and refers to a similar project undertaken in Scotland using a bespoke digital patient board called PharmacyView to visibly record patients most at need of pharmacy care.6,7 In Wythenshawe Hospital, we have developed a tracker board that is similar to the PharmacyView system in several ways including: the ability to prioritise patients most at need of pharmaceutical care and visibility of the status of discharge prescriptions for pharmacy and nursing staff. The prioritisation process used with PharmacyView is described as allocation of triage status by clinical pharmacists, although the method for this is not described. However it is likely to be a similar principle to the pharmaceutical acuity level assignment utilised in the tracker boards. In addition to the functional similarities between PharmacyView (TrakCare) and the tracker boards (allscripts), we have included the ability to record when Medicines Reconciliation is performed, to log each time a patient is reviewed by a member of the pharmacy team and when a check of patients own drugs (POD)/in-patient medication supply is undertaken. These additional functions have given us a greater degree of data intelligence regarding our workload and productivity, which has enhanced our ability to deliver our services efficiently. 
 
The benefits of our model of service delivery has an impact at multiple points along the patient’s hospital stay including on admission (by improving the timeliness of MR and the associated benefits of this such as reduced potential for adverse events as a result of unintentional discrepancies),8 during the in-patient stay (by improved opportunities for pharmacists to optimise patients medication following medication reviews due to a more efficient and dynamic use of the workforce) and also at discharge as evidenced by improvements in the time taken to process discharge medication.
 
Assigning pharmaceutical acuity levels to patients allows prioritisation of patients with the greatest need of pharmaceutical care, who as per our departmental standards, receive the highest frequency of pharmacist review and whose pharmaceutical care is delivered by a senior pharmacist.
 
Tracker board intelligence allows improved supply of medicines to patients (via targeted medication supply check), which could have a positive impact on reducing missed doses and the timely processing of discharge prescriptions. Conducting prompt medicines reconciliation resolves medication related problems early in the patient stay thereby reducing length of stay and delays at discharge.9 Both of these elements have a positive impact on patient flow.
 
Ultimately this is likely to have positive effects on patient experience. In turn, good patient experience has a positive impact on improvements in patient safety and clinical effectiveness.10
 
Assessing the impact of clinical pharmacy services on patient care is challenging and our role in medicines optimisation encompasses far more than MR and management of discharge prescriptions. However, the significant increase in the percentage of patients with a completed MR within 48 hours of admission (p=0.001) coupled with the improvement in discharge prescription dispensing within 2 hours from 61% to 90% demonstrates our enhanced ability to manage our workload by the flexible use of our staff.
 
Our new model of service delivery was a vital component in our ability to deliver services in a crisis. The day following the Manchester Arena bombing, we were able to manage the task of discharging high volumes of patients while ensuring clinical pharmacy services were delivered throughout the hospital. The tracker board allowed the effective co-ordination of the pharmacy workforce. Despite high demands on our service and depleted staffing levels due to many staff working through the previous night, standards for service delivery were maintained. 
 
The changes implemented have been positively received by our staff, as demonstrated by the responses recorded in the staff survey, which showed that staff wanted the new model of service delivery to continue and stated that they found it supported them in their role. A response rate of 21% was recorded for the staff survey. A limitation to our survey is that the invitation to participate was emailed to the entire pharmacy department so as not to prevent any members of staff expressing a view. However, within the department there are many staff employed in roles other than ward-based clinical pharmacy services, so although the response rate would not be considered high, this can be explained by the fact that the invitation to participate was sent to a far larger group than those staff directly involved in ward-based clinical pharmacy services.
 
Our directorate team-based structure, coupled with the allocation of senior staff to support delivery of care to patients with a high pharmaceutical acuity level supports less experienced members of staff in their development. The clinical co-ordinator role is another vital support mechanism for staff so that at times when workload exceeds their capacity, additional resource is identified and provided. This benefits both patients and staff.
 
For managers of the clinical pharmacy service, the introduction of the tracker board is a valuable tool for quality assurance of the service. Prior to the introduction of the tracker board a manager’s only way of confirming if all patients had had the correct frequency of review would be to visit a ward and check each prescription chart. The reporting functionality of the tracker board allows managers to be confident that the service delivered each day meets with our clinical pharmacy standards. The introduction of the new system was intended as a means of improving our service and although not an objective of the project, the tracker board data can provide information relating to the productivity of teams and individuals. This data can be useful when managing performance-related concerns.
 

Conclusions

The aim of this piece of work is continual service improvement using a flexible service model. The new system of work has improved the delivery of clinical pharmacy services by targeting the workforce based on patient risk and an accurate knowledge of workload. This had led to a more efficient use of the resources we have for delivering clinical pharmacy services resulting in demonstrated improvements both in our ability to deliver core services (such as medicines reconciliation and the processing of discharge prescriptions) as well as patient safety. Our next challenge is to translate our services into a model that delivers the same level of pharmaceutical care across seven days.
 

Acknowledgements

We thank Charlotte Skitterall, Chief Pharmacist; Dr Beatriz Duran, MFT, Wythenshawe and Withington Lead Research and Innovation Pharmacist; Laura Coatsworth, Lead Pharmacist for Electronic Prescribing; and the ward-based clinical pharmacists and pharmacy technicians.
 

References

1 Franklin B et al. The evaluation of a novel model of providing ward pharmacy services. Int J Clin Pharm 2012;34(4):518–24.
2 Hickson RP et al. Evaluation of a pharmaceutical assessment screening tool to measure patient acuity and prioritise pharmaceutical care in a UK hospital. Eur J Hosp Pharm 2016;10:1136. 
3 Saxby KJE et al. Pharmacists’ attitudes towards a pharmaceutical assessment screening tool to help prioritise pharmaceutical care in a UK hospital. Eur J Hosp Pharm. Published Online First 20 December 2016 (Publication).
4 Royal Pharmaceutical Society. Professional Standards for Hospital Pharmacy Services. December 2017.
5 Department of Health. Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. February 2016.
6 Royal Pharmaceutical Society. Updating the RPS Professional Standards for Hospital Pharmacy 2017 – Literature Review.
7 NHS Scotland. eHealth Good Practice Case Studies (online). www.ehealth.nhs.scot/case-studies/ (accessed May 2018). 
8 National Institute for Health and Care Excellence. Medicines optimisation: The safe and effective use of medicines to enable the best possible outcomes. www.nice.org.uk/guidance/ng5/resources/medicines-optimisation-the-safe-a... (accessed May 2018).
9 Cadman B et al. Pharmacist provided medicines reconciliation within 24 hours of admission and on discharge: a randomised controlled pilot study. BMJ Open 2017;7:e013647.
10 Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013: http://bmjopen.bmj.com/content/3/1/e001570.full

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