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The statements: a reflection on the results
  1. Roberto Frontini
  1. Correspondence to Dr Roberto Frontini, European Association of Hospital Pharmacists, Rue Abbé Cuypers, 3, Brussels B-1040, Belgium; president{at}eahp.eub

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The overarching goal of the hospital pharmacy service is to optimise patient outcomes through working collaboratively within multidisciplinary teams in order to achieve the responsible use of medicines across all settings.

With an excellent score of 93.6% of the maximum possible agreement level, participants at the European Summit on Hospital Pharmacy in Brussels approved this first statement leading our profession into 2020 and beyond. The statements are concise sentences setting out tasks and a vision of the skills and competencies we should develop and maintain.

Translating the overarching first statement into practice is not easy: ‘optimise’ means excellence should never lead to complacency and that under-developed practice must move step by step towards excellence. Inertia and frustration at a lack of resources are not an option. Creativity is required and we should enjoy each small step aimed at improving the outcome of our patients.

Achieving the best outcome for patients is not restricted to pharmacists: the statements are the result of a robust Delphi process where patients, physicians and nurses helped us understand their needs and adapt our practice goals to the entire process.

‘Working collaboratively with multidisciplinary teams’ is a challenge and an opportunity at the same time; a challenge as we have to develop social competency in dialogue with other healthcare professionals and patients, and an opportunity as our skills will be recognised by patients and professionals as we interact with them and take responsibility for our advice. The unknown pharmacist in his pharmacy is not the future of our profession.

‘Responsible use of medicines’ refers to a carefully balanced decision between effectiveness, medication safety, the patient's needs and wishes, as well as financial cost. This is not an easy task especially in times of austerity if the requests of patients do not accord with economic constraints. ‘Responsible’ means considering both the individual and society as whole. Finding the correct balance requires empathy, creativity and knowledge of all the processes involving medicines. In addition, we have to balance evidence of effectiveness with possible risks for the individual patient. And finally ‘across all settings’ gives us a huge responsibility to ensure patient safety during transfers into or out of the hospital and also within the hospital, for example, from the intensive care unit to the ward. We know that transition is challenging and that communication gaps put patients at risk. This is confirmed by the strong agreement with statement 4.5 on seamless care by all participants. Developing social competencies and working in teams is therefore necessary if we want our pharmaceutical competency to provide additional benefit for the best patient outcome.

All statements had a high level of agreement and provide a robust foundation endorsed by patients, physicians, nurses and pharmacists. Nevertheless, it is interesting to analyse some of the statements in more detail. A strongly agreed position, as achieved for 45% of the statements, may have a higher priority for implementation. Hospital pharmacists have to assume leadership and make these goals a reality in all hospitals. As long as there are huge gaps between statement goals and reality, we have to fight for the safety of our patients, which is the basis of all the statements.

The highest level of agreement among all groups was achieved for statements 3.4 and 5.11. These statements together with 5.10 set out the need for traceability and quality in the medication process whether or not the medicines are procured or produced by the pharmacy. Traceability is essential for patient safety and must be given priority in all hospitals. Examination of data from the last European Association of Hospital Pharmacists (EAHP) survey shows that action is needed across Europe. The use of appropriate technology including barcodes may help achieve this goal without a requirement for extra staff resources. Pharmacists have to claim and retain leadership in this process. Finally, as emphasized by the strongly agreed statement 2.1, procurement should be based on the principles of medicine safety, quality and efficacy.

Another statement achieving a high level of agreement among all groups is 5.6. This statement like statement 1.3 is challenging for hospital pharmacists: we need to identify high-risk medicines and prioritise our actions especially where human and other resources are lacking. But in setting our priorities, we must always remember that the patient comes first. Sometimes this position will mean that the pharmacist is a lone voice in the clinical team fighting against personal interests and waste of resources.

Statement 4.6 also received strong agreement and covers another interesting issue. Informing patients as well as physicians and nurses about the best use of medicines is a key competency of pharmacists, but pharmacists are not always properly trained in do this ‘in terms the target group can understand’. Pharmacy education and professional development should focus on teaching empathy and the social competencies necessary for adapting our language to the targeted group. Without this translation of our pharmaceutical competencies, patients and other healthcare professionals will not see the added value of collaboration with pharmacists!

Seamless care is another goal on which all participants strongly agreed (4.5). Seamless care also depends on proper communication between the hospital and community settings and also between different wards and units of the hospital. Such interfaces can generate errors if not managed properly; unfortunately reimbursement systems and hospital policies do not always recognise the need for such management. This is unacceptable from a patient perspective and we should demand the proper coordination essential for continuity of care.

Examining the results in more detail, we can analyse those statements where different groups had different levels of agreement. This may help us develop strategies to guard against possible barriers and ensure open communication with our colleagues.

Statement 3.6 on the reconstitution of medicines on the ward and statement 5.9 on the need for information at the point of care reveal differences between pharmacists, patients and healthcare professionals. Other healthcare professionals are not as enthusiastic as pharmacists and patients in looking for written procedures approved by pharmacists. We do not know the reason for this, but nurses and doctors handling medicines daily on the ward are possibly not sufficiently aware of the risks and complexity of such procedures, and do not see the need for additional information at the point of care. Therefore, we should put more energy into creating awareness of possible errors and related risks.

A similar situation also arose for statement 4.7 on off-label use. In contrast to pharmacists and patients, other healthcare professionals do not see the need for advice by pharmacists. Patients strongly agree that guidance by pharmacists is required and they seem to trust pharmacists more than physicians and nurses where medicines are involved. Pharmacists must be more proactive in achieving recognition by other healthcare professionals as the experts in medication. Creating trust is a long process, once again based on our pharmaceutical as well as our social competencies.

Some controversial results, as in 1.2, 1.5 and 1.7, might be only due to the fact that patients and other healthcare professionals do have not sufficient experience in the fields covered by the statements and thus are not able to provide an informed opinion. Similarly, the different levels of agreement for the statements concerning the medication processes, technology and formulary (2.2, 2.3 and 2.4) may be based on insufficient knowledge of the procurement processes, as well as the ‘seven rights’ mentioned in statement 5.1.

The differences in agreement with statement 4.3 on access to patient records and the documentation of pharmaceutical interventions is remarkable. Patients may be worried about the confidentiality of data as well as healthcare professionals in relation to the documentation of their interventions. It is crucial for pharmacists to be more integrated into the care team, and access to records as well as documentation of pharmaceutical interventions is paramount for achieving this goal. No visibility in the patient's record means no visibility as a profession.

We also need to understand why the need for external quality assessment accreditation programmes is not better supported by healthcare professionals (statement 5.3). There is no reason to avoid appraisal by external reviewers as it is an important step for quality improvement. Bad experiences by physicians and nurses in systems perceived as more as rigid than supportive may be the reason for such disagreement. We have to show that we support external evaluation to ensure the quality of service to patients.

Patients and other healthcare professionals also have slightly different opinions on the necessity for research on hospital pharmacy practice (6.4). This finding is an incentive to undertake more research and publish the results similarly to physicians. Lack of published studies probably also contributes to the lack of visibility. We have to show that pharmacists’ work has a strong foundation of scientific research.

Finally, it is remarkable that statement 4.2 on the review and validation of all prescriptions as soon as possible by a hospital pharmacist achieved the lowest level of agreement including among pharmacists. The most probable explanation is that all participants were worried about a possible delay in treatment. However, such review should be understood as a quality step and not as a barrier in the medication process. We will have to decide on the basis of each hospital's resources whether such a review would be possible in time and whether it would improve medication quality. Therefore, risk assessment is a key issue in this process also.

Individual situations in different countries and different hospitals will require different priorities regarding implementation, for example, if shortages are a major problem or IT technology is poor.

Table 1 gives details of the agreement for all statements. Online supplementary table S1 shows a selection of the highest and lowest levels of agreement in total and by different groups. This table may help clinicians set local priorities.

Table 1

Level of agreement achieved in total and by group

With the 44 statements agreed by pharmacists, patients and healthcare professionals, EAHP has created a shared vision of our profession, but the reality in Europe may be different. It is important to understand that current practice may be quite different from statement requirements. Some may argue that the aspirations expressed in the statements will be never possible in some political environments and are even in conflict with current practice and legislation. But as the great philosopher Jürgen Habermas said: “Where the oasis of utopia dries out only a desert of banalities and helplessness will spread”. We need dreams to move us on and frustration with the status quo is no reason to give up. EAHP has examined the role of hospital pharmacists and created these statements in order to ensure the best outcome for patients. This should be the only goal of our profession. Knowing the harbour we have to reach, we can use favourable winds to adjust the direction of travel.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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