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Abstract
The European Statements of Hospital Pharmacy are a set of hospital pharmacy practice standards published by the European Association of Hospital Pharmacists (EAHP) for European health systems to ensure safe, effective and optimal use of medicines in collaboration with multidisciplinary teams. Keele University was commissioned to conduct a survey among European hospital pharmacists to establish a baseline to assess awareness of the Statements and to identify any barriers to their implementation. The survey was conducted from January 2015 to March 2015, spanning 16 languages and 34 countries. The survey consisted of three sections:
▸ Section A: general questions about the participant's hospital pharmacy, such as workforce skill-mix and number of beds served;
▸ Section B: questions about the current activity of pharmacists around each statement;
▸ Section C: questions about the hospital's readiness and ability to implement the statements.
In section B, a value was allocated to each response to rate the degree to which they were able to comply with each statement (where 1=never able to comply, 5=always complied). In section C, they were asked to what degree they agreed with the question (1 for strongly disagree, 5 for strongly agree). A response of 1 or 2 was deemed to indicate some difficulty in complying with that statement—a ‘negative response’. Where this was the case, the participant was given the option to provide a free text response explaining the reasons for this difficulty.
The full results are discussed in a subsequent paper (see page 69). Overall, the response rate was 18%, but the variation in this was marked. 22 of the 34 countries had a response rate of over 30%. The methods used for this survey results informs the methodology and scope of future EAHP surveys
Recommendations for future surveys are as follows:
▸ Keep the survey short and easy to complete (to within 20 min);
▸ Specifically enquire for each question if capacity and capability are the key barriers to implementation;
▸ Construct survey response options for each question to identify barriers other than capacity and capability;
▸ Identify the key drivers for change in countries where implementation has occurred or is occurring;
▸ Compile better intelligence about the number of surveys sent out in the first place (as those countries with a low response rate sent out lots of invites to participate which may be unrealistic);
▸ A named person (country coordinator) to send out invite survey link;
▸ Weekly reminders should be sent out by the named person (country coordinator).
- EAHP Statements
- AUDIT
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Introduction and background
The European Statements of Hospital Pharmacy are a set of hospital pharmacy practice standards compiled and published by the European Association of Hospital Pharmacists (EAHP) for European health systems to ensure safe, effective and optimal use of medicines in collaboration with multidisciplinary teams.1
The statements were formulated following an 18-month review process, which included two rounds of online Delphi consultation with EAHP’s 34 member country associations and patient and healthcare professional organisations and a ‘World Café’.2 As outlined by Horák et al3 in their report on the future of the EAHP survey, implementation of the Statements remains a challenge. Generally, the biggest challenges in implementing the Statements are perceived to be around the varying levels of practice, the different healthcare systems and problems with staffing (capacity and capability). In order to facilitate better implementation of the Statements, it is essential to capture a baseline of where different countries are now in relation to each Statement and then measure their progress on a regular basis. Based on previous feedback and the Summit, EAHP decided to change its data collection tool, the EAHP survey, by designing a shorter annual survey, optimising data collection while minimising workload for survey respondents. The primary focus of the annual survey is to identify the barriers to the implementation of the Statements.
The Keele Centre for Medicines Optimisation at Keele University was commissioned in September 2014 to conduct a survey among European hospital pharmacists to establish a baseline to assess awareness of the Statements and to identify any barriers to their implementation.
Method
Survey development
The survey was drafted following a meeting of the EAHP Survey Group facilitated by two external consultants (CMcK and JU) where the pros and cons of several question styles were discussed and agreed. The initial draft of the questions were commented on by the EAHP Survey Group and then sent to each country coordinator for comment. These comments were incorporated to produce the final version.
It was agreed by the EAHP Survey Group that the survey should only ask questions based on statements that had a resonance at an individual hospital level. The remaining statements which could only be responded to at a national level were statements 1.2, 1.4, 4.7, 5.1, 6.1 and 6.5. The EAHP conducted a separate survey for these statements, with the results of the questions relating to those statements reported as an appendix to the overall report, published on the EAHP website.
The survey was created by NG using the online survey software SurveyMonkey. This allowed the survey to incorporate a variety of question formats and necessary logic, while incorporating EAHP branding and logos.
Survey design and format
The primary focus of the survey was to identify the barriers in the implementation of the European Statements of Hospital Pharmacy. To achieve this aim, the survey (see appendix 1) consisted of three sections:
Section A: general questions about the participant's hospital pharmacy, such as workforce skill-mix and number of beds served.
Section B: questions about the current activity of pharmacists around each statement.
Section C: questions about the hospital's readiness and ability to implement the statements.
In section B, the pharmacists who participated in the survey were asked to rate the degree to which they were able to comply with each statement. A value was allocated to each response using a scale of 1–5, where 1 indicated that they were never able to comply with the statement, while 5 indicated that they always complied with the statement. In section C, they were asked to what degree they agreed with the question and the same Likert scale was used (1 for strongly disagree, 5 for strongly agree).
For the purposes of identifying those statements where the barriers to implementation were greatest, a response of 1 or 2 was deemed to indicate some difficulty in complying with that statement—a ‘negative response’. Where this was the case, the participant was given the option to provide a free text response explaining the reasons for this difficulty.
The survey was designed to only prompt for a free text response when the participant gave a negative response. By doing this, the logistical burden of dealing with vast amounts of free text (both translation and analysis time) was minimised, while still enabling the barriers to be identified by responders. For these reasons, it was also decided that all free text responses should be limited to 200 characters, prompting participants to answer concisely. Participants were also given the option to email a full response if they felt the need to.
Translation of the survey into 15 languages other than English was facilitated by EAHP staff using country coordinators to check the translated text for their own country. The translated survey text was then sent back to Keele and entered into SurveyMonkey. The same process was used for the translation of free text from the completed surveys.
Completion of the survey
The survey was conducted from January 2015 to March 2015, spanning 16 languages and 34 countries. Access to the survey was through a web-link, meaning that anybody with access to the link could complete the survey. NG sent a link to the survey and a list of unique codes to an EAHP coordinator who distributed the survey to the recipients and could track responses. In cases where a country did not wish to share the emails of their pharmacists, the EAHP sent the link and codes to a coordinator within the country to distribute themselves.
When the user started the survey they were asked to input their unique code, which allowed the survey administrators to check that only people invited to the survey were responding. This also enabled monitoring of response rates to the survey, where weekly reminders could then be sent to those who had not yet replied.
Survey analysis
When the survey closed, there were a total of 1094 responses, the results of which were exported from SurveyMonkey by NG for further analysis and reporting. For each country, the percentage of ‘negative responses’ was calculated for each question with the five questions receiving the highest proportion of negative responses identified for each country. The advantage of using this method instead of the mean meant that the views of each country were considered equally, despite the fact that there was a large variation in the number of responses received for each country.
Survey response rates
The response rates of completed surveys are listed in table 1, broken down by country. If an incomplete survey was submitted, the quantitative data were not used in the results, although any free text responses were still incorporated. For the majority of cases, the country's coordinator provided a list of emails for person they wished to include in the survey, a unique survey code was generated for each person and the EAHP distributed the survey. However, the countries highlighted in red (table 1) used a different distribution method and were instead provided a list of unique codes to allocate and distribute to people themselves (table 1).
Response rates to the survey by country
Discussion and recommendations for future surveys
The results of the baseline survey are discussed in a subsequent paper (see page 69), and how this informs the EAHP implementation strategy the subject of another further paper (see page 76).
The method used for this survey provides a good overall baseline picture of where the different member countries are in relation to each of the Statements. Overall, the response rate was 18%, but the variation in this was marked. Of the 34 countries, 22 had a response rate of over 30% which is in line with the response rate seen for previous EAHP surveys. Those countries where lots of surveys were sent out were the ones who tended to have lower response rates. This should inform the methodology used for future surveys where better targeting of the survey is recommended to increase the percentage response rate.
The survey was designed to ease the burden of translating large amounts of free text responses by only asking for free text responses if the participant responded negatively to a question, and to limit the response to 200 characters. Despite this, translation of free text still proved to be a significant task.
One solution to this problem for future surveys would be to identify key barriers to implementation from the results of this survey (eg, capacity and capability) and provide future survey participants the ability to select options from a list of key barriers to implementation. The participants would then only need to provide a free text response if they encountered barriers not in the list of options.
Recommendations for future surveys:
Keep the survey short and easy to complete (to within 20 min)
Specifically enquire for each question if capacity and capability are the key barriers to implementation
Construct survey response options for each question to identify barriers other than capacity and capability
Identify the key drivers for change in countries where implementation has occurred or is occurring
Compile better intelligence about the number of surveys sent out in the first place (as those countries with a low response rate sent out lots of invites to participate which may be unrealistic)
A named person (country coordinator) to send out invite survey link
Weekly reminders should be sent out by the named person (country coordinator)
What this paper adds
What is already known on this subject
The European Statements of Hospital Pharmacy, expressing commonly agreed objectives which every European health system should aim for in the delivery of hospital pharmacy services, were prepared and approved in 2014.
Implementation of the European Statements of Hospital Pharmacy is a key priority for hospital pharmacy.
There were no specific data describing the level of implementation and main barriers to this.
What this study adds
The baseline survey aims to identify the barriers and drivers of implementation of the Statements.
The methods used for this survey results informs the methodology and scope of future European Association of Hospital Pharmacists surveys.
Acknowledgments
EAHP Survey Working Group: Petr Horák, Joan Peppard, Juraj Sýkora, Tajda Miharija Gala, Leonidas Tzimis, Ercan Celikkayalar Adil and Vera Pires. Ms Jennie De Greef and EAHP staff. EAHP member association presidents and national survey coordinators. Cheryl McKay (CMcK), managing director, Kayhill Consulting (http://www.kayhillconsulting.com/).
Appendix 1
The table below shows all of the questions asked in the survey regarding the 44 European Statements of Hospital Pharmacy, as well as the overall percentage of participants who gave a ‘negative response’ to the question. Questions where more than 25% of participants gave a negative response have been highlighted in red.⇓
Footnotes
Contributors The survey group, NG and JU were involved in planning of the study, design of the questionnaire and conducting of survey. CMcK was involved in the initial planning of the survey. NG set up the online form, along with respective language mutations. NG, JU and PH were involved in data evaluation and statistics. JU and NG drafted the article and revised for content; JU had final approval of the version to be published.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.