About this chapter

This chapter encourages the use of evidence across the whole of hospital pharmacy practice. It introduces the concept of knowledge brokering and argues that all activities including pharmacy management should be evidence based.

Decision making

For many of us, decisions are made based on opinion. Pharmacy managers run departments based on what in their view works or what was done by their predecessor. One of us (PW) remembers moving into a new job quite a few years ago. It was quickly apparent that the programming of the day’s work meant that staff were not covering their clinical pharmacy activities until late in the day such that most staff were working well beyond the closing time. When asked why this was so, the response was ‘we have always done it this way’. In addition, good working practice was hampered by the physical layout of the department. In this and similar cases, there is a need to change things based on three key factors: evidence, values and available resources. In this late working scenario values and available resources played a higher role than evidence. Staff valued getting home at a reasonable time and there were already sufficient resources to deliver services earlier in the day. When changes were implemented after a good deal of discussion and the changes were audited (important) pharmacy staff were happy and nurses reported that the changes made improvements to their working day also.

The skills required to improve decision making are the same as those discussed in previous chapters:

• Ask the right question and convert it to something that can be answered.

• Find evidence.

• Assess the quality of the evidence.

• Decide if the evidence is applicable to the local situation.

• Make the changes required.

Clearly we may not have high level evidence to support a change in practice but usually some form of evidence is available. If we consider a major change such as implementing robotic dispensing, evidence (written or verbal) from those who have been down the same route can be vital. Their perspective on what worked and what problems arose can help smooth implementation. That evidence needs to be considered alongside values and resources.

In addition, research in business decision making process can be used in many areas of pharmacy practice, to serve as the evidence base for change. Concepts such as the study of ‘organisational behaviour’, ‘coaching’ and ‘performance improvement’ can be used in healthcare to facilitate the ‘out-of-box’ thinking for pharmacy services. It is perhaps surprising that healthcare is very slow in adopting new technologies, so that even now electronic medical record systems are not unified or easily accessed. On the other hand, sensitive and personal information such as banking details can be accessed easily through online banking or telephone banking.

What is evidence: a reminder

The Nuffield Council on Bioethics1 has a useful document on evidence-based policy and process issues; it reiterates what we have said before about evidence:The adoption of an evidence-based approach brings with it certain assumptions as to what constitutes good evidence, and it is important to scrutinise carefully any source of evidence. For example, media stories often turn out to be based on anecdotes, unpublished reports or preliminary results, or they overstate, misrepresent or misunderstand the claims of the researcher. The minimum hurdle for evidence to be reported (or to be considered in public health policy more generally) is that it should be published in the peer-reviewed literature, or have been subject to an equivalent scrutiny by expert peers. This hurdle by no means guarantees that the evidence is irrefutable as, for example, the quality of papers accepted varies greatly between scientific journals. However, peer review suggests a certain robustness as findings are scrutinised by experts in the field and research is open to repeat investigation.

Doing things better and doing them right

We live in times where peoples’ expectations are rising whether that is for our patients, our healthcare colleagues or our pharmacy staff. Unless we are aware of those expectations, we can continue on our way without realising the problems we cause. For example, we may consider a 30 min wait for a patient to collect their discharge medicines to be acceptable. For them it may cause a whole host of problems related to relatives’ availability, car parking and stress on a sick person who just wants to get home. Angela Coulter2 discussed expectations some 10 years ago in an editorial titled ‘Examining health expectations’. She discussed the importance of healthcare workers developing a better understanding of patients and their expectations. In this context, she suggests that we consider a number of questions, some of which are quoted below:

• How often are expectations unrealistic?

• If these unrealistic expectations are a real problem, how can they be modified?

• What is the relationship between expectations and preferences?

• Could measurement of patient satisfaction be improved by greater attention to prior expectations?

• To what extent is there concordance or dissonance between patients’ expectations and those of health professionals?

• Do health professionals understand patients’ expectations and in what ways do these influence their behaviour?

• Could high expectations act as a catalyst to quality improvement?

Given our discharge scenario above, it is clear that the waiting is dependent on a variety of factors which may not be the responsibility of pharmacy staff. That does not mean that pharmacy cannot be a part of the solution. Patients may be delayed for all sorts of reasons which include availability of medical staff to write the discharge or even the availability of staff to take the prescription to pharmacy. Is there good evidence that pharmacists can safely prepare discharge prescriptions? Is there good evidence to support electronic transfer of prescriptions? There will be an evidence-based solution to this problem.

Evidence base pharmacy management

Muir Gray in his book Evidence-based Healthcare and Public Health3 has a section on health service management. We have borrowed his headings with permission for pharmacy management.

1. Create the context for an evidence-based pharmacy department

   There are two key components for this: first, the pharmacy needs the capacity to generate evidence (and publish this) as well as the means in the form of will and resources to act on the evidence. Second, there needs to be expertise within the organisation to find and appraise the evidence. For many, this will require a cultural change and bring a much stronger emphasis on learning.

   Some such as Peter Senge talk of learning organisations.4 This will involve the establishment of shared visions from head of department to others lower down and also from the roots upward; it also requires the establishment of functional teams where the collective intelligence is far more than the sum of the parts. To work in such an environment is both stimulating and satisfying. Hospital pharmacy is already knowledge rich around many of its core activities such as medicines use and medicines information. We perceive it remains largely knowledge poor about the best ways to run its services and much remains time honoured rather than evidence based.

2. Develop the right culture

   Leaders have power—that may seem obvious but language and behaviour are vital in setting the right culture. Observing many hospital pharmacy departments over a number of years, it is easy to spot those that have a culture where staff are respected and given space to develop and those who languish under restraints and restrictions. An evidence-based organisation starts at the top and the role cannot be delegated to a more junior member. This means that decisions are taken with a careful look at any reliable evidence and the use of this evidence is documented in meeting minutes or other records. There is a history of organisations appointing a chief knowledge officer to manage requests for evidence and developing systems to deliver what is needed. This role is almost certainly to be outside that of the head of department but should report directly to the senior level.

3. Systems

   To support an evidence-based organisation, systems need to be in place to facilitate the provision of evidence and ways of promoting evidence. Fundamental to this will be access to the internet and subscriptions to evidence resources such as Medline (not just PubMed), Embase and the Cochrane Library. This may seem obvious but the information technology policies of many hospitals seem to militate against this motivated by fears of computer security breaches. Personnel with information management skills can be really helpful in provision of evidence.

   Existing practices can be used to promote the use of evidence. The obvious one is clinical pharmacy, which has been discussed widely in these chapters. Many pharmacists play a role in clinical audit, which is another area where evidence can add value. Other initiatives such as the development of guidelines and care pathways are areas needing good evidence provision.

   Medicine committees (aka Drugs and Therapeutic Committees) have a huge demand for high-quality evidence. Some of this may be in the form of trend or usage data for medicines that may lead to valuable changes in practice. Antimicrobial prescribing data is fundamental to the control of microbiological resistance and is powerful alongside evidence of how to change prescribing practices for antibiotics.5

   Finally in this section, evidence is needed for managing innovation. Muir Gray argues that new technology may enter without evaluation whereas new knowledge may not be taken up speedily. Pharmacy practices need to change to improve this.

4. Change management

   Change management theories have been tried and tested over time. The biggest impact on bringing about change is to win over opponents in a way that brings them on board. Second, change management takes time. In point 2 above we mentioned the knowledge officer. Such a person can be very useful in times of change, bringing reassurance that there is good evidence for developments. The key task of the knowledge officer is to broker knowledge.

   Morgan Meyer6 writes: ‘knowledge brokers can be understood as persons or organizations that facilitate the creation, sharing, and use of knowledge (Sverrisson8). Their task is to establish and maintain links between researchers and their audience via the appropriate translation of research findings (Lomas7). Able to link know-how, know-why, and know-who, the knowledge broker thus works in the public domain as much as in the private domain’.7 ,8

One of Morgan's cited authors—Lomas7 points out that decision makers in the British navy took over 250 years to introduce citrus juice as a routine prevention for scurvy. The benefits were first demonstrated in 1601!

Fighting giants!

Every so often there are major issues that need to be fought for. In most cases these are not easy battles and the opposition can be fierce; nevertheless, they are worth fighting for. The older readers of European Journal of Hospital Pharmacy (EJHP) will recall at least two major battles. We also discuss two newer developments—that of pharmacists prescribing and obtaining remuneration for pharmacy services.

1. Establishing clinical pharmacy

   There was a time when clinical pharmacy did not exist in many countries and even today is still not established in others. The early battles were against entrenched clinical colleagues who felt pharmacists were best placed down in a basement pharmacy in the hospital and all was well as long as the medicines arrived. Evidence started to emerge that clinical pharmacy saved lives and saved money. Eventually, medical staff realised that clinical pharmacists added value to what they did and in some cases they were less busy due to pharmacists work. In many countries the clinical role is now well established and demanded by medical staff.

2. Accessing and writing in patients’ notes

   In order to practice clinical pharmacy, it soon became apparent that pharmacists need to see patients’ notes in order to understand the issues that related to medicines. All sorts of arguments were made against this including the one of patient confidentiality. Slowly the battle was won, leading to the next fight over the right of pharmacists to add their observations to patient notes. We still live in a heterogeneous world where in some hospitals pharmacists annotate notes but in others it is not permitted—even in the same country. The situation is changing as we move more into electronic patient records but even here pharmacists will need to argue for their right to add information.

3. Pharmacist prescribing

   Pharmacist prescribing is relatively common in the UK among specialist hospital pharmacists. The battle for this was not as intense as nurses had pioneered the way. In fact, pharmacist prescribing was quite logical as pharmacists’ knowledge of medicines is usually superior to that of nurses. Also, many pharmacists effectively prescribe but get their recommendations signed by a medical doctor.

4. Reimbursement of pharmacy services

   Many countries are acknowledging the pharmacists’ values in dispensing and additional services through reimbursing dispensing fees and other service charges. The examples are Medicines Use Review service in the UK or MedsCheck in Australia. In many other countries, there is still a case for negotiating the terms of reimbursement for pharmacists’ services. For example, in China, the pharmacists do not get any dispensing fees, and the revenue is generated through selling medications only. It is then apparent to be a conflict of interest if the pharmacist also wants to reduce the overuse of medications. The challenge of course is then to set apart a service charge to pay for the pharmacists’ service or the clinical pharmacy service. In the United States, following the ‘Affordable Care Act’, the pharmacists are working on obtaining provider status and bill the payers to improve the outcomes for the patients.9

Finding evidence

Information on wider pharmacy services is available but needs a little more effort to find. There are two databases that can be a good source of information. International Pharmaceutical Abstracts (IPA) is published by Thomson Reuters on their EBSCO platform. This was formerly produced by the American Society of Health-System Pharmacists. It covers some 750 journals with a strong US focus. CINAHL (Cumulative Index of Nursing and Allied health literature) comes from the same publishers. It does not cover the same range of pharmacy journals as IPA but is more readily accessible in many hospital libraries.

The common databases such as Medline and Embase are also worth searching. A brief recent search in Medline on clinical pharmacy services revealed some 15 000 hits, many outside the recognised pharmacy literature. A Medline search of medical records and hospital pharmacist provided some 500 hits.