PRACTICE REPORTS Pharmacy residency program
PRACTICE REPORTS
Implementation of a nontraditional postgraduate year 1 pharmacy residency program Khenh S. Vong, Kevin A. Koons, and Paul A. Carnes
Scan to access AJHP podcasts
I
An audio interview that supplements the information in this article is available on AJHP’s website at www.ajhp.org/ site/misc/podcasts.xhtml.
n 2003, the American Society of Health-System Pharmacists (ASHP) launched the ASHP Health-System Pharmacy 2015 Initiative with the intent to improve the practice of pharmacy in hospitals and health systems by promoting public health and ensuring that medication use is safe, effective, and evidence based. As pharmacy practice evolved, the Pharmacy Practice Model Initiative (PPMI) was introduced in 2010 and supplanted the ASHP HealthSystem Pharmacy 2015 Initiative.1 The goal of the PPMI is to significantly advance the health and well-being of patients by developing and disseminating a futuristic practice model that supports the most effective use
Purpose. The development and implementation of a nontraditional pharmacy residency program at a Veterans Affairs medical center (VAMC) are described. Summary. The nontraditional pharmacy residency program at Lebanon VAMC was designed in accordance with the ASHP accreditation standard. The residency program was structured to meet staff needs without compromising patient care or significantly affecting the pharmacy services provided. The purpose statement, intended outcomes, and learning goals and objectives of the nontraditional pharmacy residency program were formulated to be equivalent to those of a traditional one-year pharmacy residency program, enabling practicing pharmacists to obtain similar overall learning experiences. The nontraditional residency program at Lebanon VAMC spans two years. The nontraditional program structure is based on a four- to six-week residency learning ex-
of pharmacists as direct patient care providers.2 ASHP and the American College of Clinical Pharmacy (ACCP) advocate residency training as a pre-
Khenh S. Vong, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Veterans Affairs Southern Nevada Healthcare System, North Las Vegas; at the time of writing she was Clinical Pharmacy Specialist, McAllen Outpatient Clinic, Veterans Affairs Texas Valley Coastal Bend Health Care System, McAllen, TX. Kevin A. Koons, Pharm.D., BCPS, is Assistant Chief of Pharmacy; and Paul A. Carnes, Pharm.D., M.S., FACHE, is Chief of Pharmacy, Lebanon Veterans Affairs Medical Center, Lebanon, PA. Address correspondence to Dr. Vong at the Southern Nevada Healthcare System, 6900 North Pecos Road, North Las Vegas, NV 89086 ([email protected]).
perience that alternates with a comparable time in the work schedule. Each required or elective learning experience ranges from four to six weeks. Longitudinal learning experiences may extend up to two years. One pharmacist was matched and began the residency in July 2012 as the inaugural nontraditional postgraduate year 1 (PGY1) pharmacy resident at Lebanon VAMC, the second institution to implement the nontraditional program within the Veterans Health Administration. The resident is expected to complete the program in June 2014 and remain committed to the Lebanon VAMC pharmacy service for a minimum of two years thereafter. Conclusion. A nontraditional PGY1 pharmacy residency program was successfully developed and implemented for pharmacists who aspire to complete residency training and improve their clinical, leadership, and preceptorship skills. Am J Health-Syst Pharm. 2013; 70:2019-28
requisite for pharmacists assuming direct patient care roles.2-4 Resident and pharmacist positions are expected to be more
This project was reviewed and approved as quality assurance or quality improvement in accordance with Lebanon Veterans Affairs Medical Center policy and procedure. This work is the authors’own and does not represent the views or opinions of the Veterans Health Administration. Presented at the ASHP Midyear Clinical Meeting in New Orleans, LA, December 7, 2011, and the Eastern States Conference in Hershey, PA, May 2, 2012. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130025
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2019
PRACTICE REPORTS Pharmacy residency program
competitive based on the projected number of pharmacy graduates reaching approximately 13,800 by 2014, an increase of more than 2,300 new graduates compared with 2011.5 Data from the 2013 ASHP Resident Matching Program (the “Match”) revealed that a total of 4,928 applicants enrolled in the Match and that 2,694 positions were offered in traditional and nontraditional postgraduate year 1 (PGY1) pharmacy residency programs.6 Of the enrolled applicants, 3,933 (80%) participated in the Match. Of these, 2,495 (63%) were matched. The 1,438 unmatched applicants had to face the “postmatch scramble” for the remaining 199 unfilled residency positions (7%) or obtain a pharmacist position without residency training. In an effort to provide residency training for pharmacists on staff, various traditional PGY1 and postgraduate year 2 (PGY2) pharmacy residency programs have expanded their programs by extending the training period over two to three years. This extension is known as a nontraditional pharmacy residency program, a strategy that enables practicing pharmacists to fulfill their current duties while completing residency training on a part-time basis. Published information regarding these types of programs is limited. The implementation of a nontraditional pharmacy residency could be valuable for the recruitment, retention, and development of staff.7 This article describes the development and implementation of a nontraditional pharmacy residency program. Background The Lebanon Veterans Affairs Medical Center (VAMC), a teaching hospital in Lebanon, Pennsylvania, with approximately 250 beds, provides a wide range of patient care services using state-of-the-art technology guided by ongoing education and research. Lebanon VAMC has six 2020
community-based outpatient clinics located in Camp Hill, York, Reading, Lancaster, Pottsville, and Frackville, Pennsylvania. Care is available to over 174,000 veterans from nine counties in south central Pennsylvania. An outreach clinic is also available at Fort Indiantown Gap, and administrative support is given to two veterans centers in nearby Harrisburg and Lancaster and a national cemetery in Fort Indiantown Gap. The department of pharmacy supports 32 pharmacist full-time equivalents, 1 VALOR (Veterans Affairs learning opportunities residency) intern, 3 PGY1 residents (traditional 12-month program), 1 PGY2 ambulatory care resident, and 1 PGY2 health-system pharmacy administration resident. Both PGY1 and PGY2 pharmacy residency programs are accredited by ASHP. Details regarding patient care services and residency programs are available from the Lebanon VAMC website (www.lebanon.va.gov). Pharmacy practice model. The pharmacy practice model at Lebanon VAMC includes both clinical pharmacy specialists and clinical pharmacists. Pharmacists use a computerized patient record system and Veterans Integrated System Technology Architecture to review patient medical records, document progress notes, enter orders, process prescriptions, and perform other numerous functions. Clinical pharmacy specialists provide direct patient care and function under an approved scope of practice with prescribing privileges. Clinical pharmacy services are available in acute care, ambulatory care (cardiovascular-risk-reduction clinic and diabetes clinic), behavioral health, extended care, hospice and palliative care, oncology (chemotherapy and epoetin clinic), primary care, and other patient care settings. Clinical pharmacy specialists are required to spend approximately 10% of their workweek in operational pharmacy services to maintain com-
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
petencies in distributive functions and to assist with establishing good rapport intradepartmentally and interdepartmentally. Clinical pharmacy specialists also provide ongoing inservice education and serve as preceptors to pharmacy students and residents. Clinical pharmacists process medication orders and dispense prescriptions; provide and document medication consultations and relevant findings in the patient’s medical record; review drug–drug, drug–food, and drug–allergy interactions; and perform other clinical activities (e.g., reconcile medications, review home-based primary care charts, attend inpatient rounds, serve as a preceptor to pharmacy students or residents). Clinical pharmacists are cross-trained and have rotating schedules in both inpatient and outpatient operational pharmacy services. Over 3000 outpatient prescriptions are processed daily at the pharmacy at Lebanon VAMC, many of which are filled by the offsite consolidated mail outpatient pharmacy. Clinical pharmacists may also spend approximately 10% of their workweek performing other special assignments. Under reasonable circumstances, a compressed work schedule may be approved to better facilitate pharmacists’ work–life balance. Pharmacy residents rotate through various learning experiences (i.e., direct patient care in clinical pharmacy services, operational services in the inpatient or outpatient pharmacy, and administrative pharmacy services) during their residency. The Lebanon VAMC pharmacy vision is to provide the highestquality, value-added pharmaceutical care to veterans. Strategic plan survey. In 2011, strategic plan surveys were conducted to align the pharmacy department’s mission and vision. The results of the surveys were tabulated and prompted the creation of six goals and numerous objectives, which are listed below. Creating a
PRACTICE REPORTS Pharmacy residency program
nontraditional pharmacy residency training opportunity for pharmacists was one of the objectives set forth to support most of these goals:
Table 1.
List of Nontraditional Pharmacy Residency Programsa Institution
1. Create a work environment that is professional, pleasant, fair, and unified while maintaining a favorable work–life balance for employees. 2. Develop strategies to improve recruitment of new staff, ensure retention of current staff, and afford opportunities for upward mobility. 3. Provide a pharmacy service that is perceived as timely, effective, comprehensive, and of necessity by all of pharmacy’s customers. 4. Develop a work force with the technical and clinical skills to meet the needs of a changing pharmacy practice. 5. Be known as a leader of pharmacy practice in our region and ensure a positive image of the department locally. 6. Effectively employ technology that optimizes efficient distributive and clinical services to allow ideal patient– pharmacist interactions.
Nontraditional pharmacy residency program A traditional pharmacy residency is a continuous, 12-month, postgraduate advanced training program. It typically begins in July and ends the following June. Although there is no established definition for a nontraditional pharmacy residency, it is presumed to be an intermittent 24–36-month postgraduate advanced training program based on the existing nontraditional pharmacy residency. Institutions with established nontraditional pharmacy residencies are listed in Table 1.6,8 The nontraditional program targets pharmacists in the work force who have not completed residency training. The commencement and completion dates of the residency are based on the term agreed upon by the institution, the residency program director (RPD), and the resident (employee). Salary and postresidency service commitment term vary by institution.7,8
Avera McKennan Hospital and University Health Center (Sioux Falls, SD) Hennepin County Medical Center (Minneapolis, MN) Henry Ford Hospital (Detroit, MI) Johns Hopkins Hospital (Baltimore, MD) Karmanos Cancer Center (Detroit, MI) Kern Medical Center (Bakersfield, CA) Lebanon Veterans Affairs Medical Center (Lebanon, PA) Memorial Regional Hospital (Hollywood, FL) Monroe Carell Jr. Children’s Hospital at Vanderbilt (Nashville, TN) Roudebush Veterans Affairs Medical Center (Indianapolis, IN) St. Joseph’s/Candler Hospital (Savannah, GA)
Program Type
Program Length (yr)
PGY1
2
PGY1
2–3
PGY1 and PGY2— Critical Care PGY1 PGY2—Oncology PGY1 PGY1
3 2 2–3 3 2
PGY1
2
PGY1
2
PGY1
2
PGY1
3
a List includes programs that are listed as participating in the ASHP Residency Matching Program or that have publicly announced the establishment of their program. PGY1 = postgraduate year 1, PGY2 = postgraduate year 2.
Residents in nontraditional pharmacy residencies are provided opportunities to enhance their competence in patient-centered care and operational pharmacy services and to further develop their leadership skills by refining their problemsolving strategies, strengthening their professional values and attitudes, and advancing their clinical judgment. Because the nontraditional residency is an extension of the traditional pharmacy residency program, it does not require supplemental ASHP accreditation survey or review. However, all PGY1 and PGY2 programs in precandidate, candidate, preliminary accreditation, conditional accreditation, or accredited status must participate in the Match conducted by ASHP, meaning that residents in nontraditional programs are required to participate in the Match. The nontraditional residency is intended to be equivalent to the traditional residency program and therefore must consist of similar Res-
idency Learning System (RLS) outcomes, goals, and objectives. Ongoing evaluation and assessment of the resident’s progress, documentation of learning experiences and completion, and resident self-evaluation are important tools that must be included in the program. The evaluation process for residents in nontraditional programs is the same as that for residents in traditional programs. At the conclusion of every learning experience and at least quarterly for longitudinal experiences, residents will evaluate the preceptor and learning experience using ResiTrak (McCreadie Group, Ann Arbor, MI). Residents, preceptors, and the RPD will meet to discuss their evaluations and provide constructive feedback. The resident’s residency performance evaluation is independent of his or her pharmacist staffing performance appraisals. Similar to residents in traditional programs, residents in nontraditional programs will be held responsible and accountable
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2021
PRACTICE REPORTS Pharmacy residency program
for acquiring the following PGY1 pharmacy residency outcome competencies: managing and improving the medication-use process; providing evidence-based, patient-centered medication therapy management with interdisciplinary teams; exercising leadership and practice management; demonstrating project management skills; providing medication and practice-related education or training; and utilizing medical informatics. In addition to completing various required and elective learning experiences, nontraditional pharmacy program residents must complete a major residency project. They are strongly encouraged to present the results of the residency project at a national meeting and are required to complete a formal manuscript of the completed project in a form suitable for publication in an appropriate professional journal. ASHP is the sole accrediting body for pharmacy residencies in the United States.9 A full review of residency accreditation requirements and program design elements are available at ASHP’s website.10 Development and implementation of the nontraditional PGY1 pharmacy residency Based on the Lebanon VAMC pharmacy department’s 2011 strategic plan recommendations, the goals of nontraditional residency program implementation included promoting staff development, advancing pharmacy practice, and facilitating pharmacy recruitment and retention. After obtaining administrator approval for the nontraditional pharmacy residency, the program was designed in accordance with the ASHP accreditation standard. The residency program was structured to fit staff needs without compromising patient care or significantly affecting the pharmacy services provided. The purpose statement, intended outcomes, and learning goals and objectives of the nontraditional 2022
pharmacy residency program were formulated to be equivalent to those of a traditional one-year pharmacy residency program, enabling practicing pharmacists to obtain similar overall learning experiences. Survey of pharmacists. In July 2011, an introduction to the nontraditional program was e-mailed to all 32 pharmacists at Lebanon VAMC. This e-mail contained a synopsis of the program and asked, “Would you be interested in applying for a nontraditional PGY1 pharmacy residency program if the opportunity existed?” A voting button with four answer choices was made available as A. Yes. I am interested. B. Maybe. I would like to receive more information. C. No. I am not interested. D. No. I have previously completed a PGY1 pharmacy residency.
Results were tabulated within two weeks. Eight pharmacists voted that they were either interested or may be interested in the nontraditional program, 8 pharmacists were not interested in the nontraditional program, 12 pharmacists indicated that they had previously completed a residency, and 4 pharmacists did not respond to this survey. Based on each individual’s response, corresponding surveys were generated and sent to subgroup A (individuals who indicated that they were either interested or maybe interested in the nontraditional program) and subgroup B (individuals not interested in the nontraditional program). No corresponding surveys were sent to subgroup C (individuals who completed a residency or did not cast their vote). Surveys of subgroups A and B allowed pharmacists to answer each question by selecting the applicable provided answer options, free text their answers, and provide additional comments or recommendations. Corresponding surveys were completed within two weeks.
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Survey of subgroup A. This survey assessed pharmacists’ preferences for the nontraditional PGY1 residency’s design and structure, their expectations of the program, and any concerns pharmacists may have related to the program. Pharmacists were asked to 1. List and rank preferences in the nontraditional program’s duration (e.g., two versus three years), program rotation structure (e.g., 1:1 versus 1:2 alternating residency and staff work rotations), and months for program commencement and completion (e.g., July through June [residency year] versus January through December [calendar year]). 2. List and rank aspirations for pursuing a nontraditional residency (e.g., increase salary; obtain clinical or management position; improve clinical, leadership, or preceptorship skills; improve task efficiency in current position; increase clinical responsibilities). 3. List and select expectations upon completion of nontraditional residency (e.g., increase salary; be promoted to a clinical position; obtain a scope of practice with prescribing privileges; maintain current position with improved clinical, leadership, or preceptorship skills; prepare for board-certification examinations). 4. List the learning experiences in which they are most interested. 5. List and select the desired practice environment after residency completion. 6. List and select the concerns they have about the residency (e.g., time management and ability to keep up with residency workload, prioritizing assignments from preceptors and staffing responsibilities, changing mindset and alternating roles from a practitioner to a resident, receptiveness to critique from preceptors [colleagues], performance evaluation, residency and staffing schedule imbalance, ability to fulfill all requirements and complete the program, program and contract commitment, restrictions
PRACTICE REPORTS Pharmacy residency program
on overtime or compensatory time, no monetary incentives, no clinical promotions).
Survey of subgroup B. This survey assessed pharmacists’ reasons for their disinterest in the nontraditional program and any potential factors that may encourage them to reconsider the nontraditional residency in the future. Pharmacists were asked to 1. List and select reasons for not being interested in the nontraditional PGY1 program (e.g., satisfied with current position, retirement within 5–10 years, possible relocation within 3 years, personal or family responsibilities, no financial incentives, extended residency program duration, residency program workload, residency program hours, inadequate baseline clinical skills, questionable competency to complete program). 2. List and select factors that would make you reconsider the nontraditional PGY1 program (e.g., financial incentives, shortened residency program duration, no contract obligations).
Of the eight recipients of the subgroup A survey, seven responded (87.5%); all eight survey recipients of the survey in subgroup B responded (100%). Most of the respondents in subgroup A were interested in a twoyear program that begins in July as opposed to a three-year program or a program that begins in January. A residency learning experience:staff work ratio of 1:1 was preferred by most respondents (e.g., six weeks’ residency learning experience alternating with six weeks’ staff work). Improving clinical, leadership, preceptorship skills; improving task efficiency; and increasing clinical responsibilities were among the top aspirations selected by respondents. Monetary incentives were not the primary reasons for considering the nontraditional program. The most common concerns were associated with time management.
In subgroup B, six respondents (75%) indicated that they were satisfied with their current positions. However, they may reconsider the nontraditional program in the future if there are financial incentives, there is no service commitment on completion of the program, or the duration of the program is shortened. Recruitment and marketing materials. The development of and recruitment for the nontraditional PGY1 program were achieved in approximately six months. Table 2 provides the development timeline and the associated residency program activities. Pharmacists who have not completed a residency may not be fully aware of what a residency entails and the preparation that is required. Meeting announcements, program brochures, and PowerPoint presentations, as well as the initial surveys, served not only as marketing tools but as informational resources
to ensure that all pharmacists at Lebanon VAMC fully understood the benefits and challenges of completing a residency. The brochure for the nontraditional residency program contained general program information; an overview and example of the rotation schedule; information about learning experiences, benefits, eligibility, and application requirements and deadlines; the program’s National Matching Service (NMS) code; contact information; and links to the Match and the existing Lebanon VAMC PGY1 pharmacy residency program brochure. The PowerPoint presentation contained supplemental information to assist pharmacists with preparing for their residency application and interview. In addition, a Q and A session was held with the pharmacists to provide any needed clarifications and information that would support decision-making.
Table 2.
Nontraditional Pharmacy Residency Program Development Timeline and Activities at Lebanon Veterans Affairs Medical Center Date
Activities
July 2010–June 2011
Pharmacy service strategic plan surveys,a formulation of strategic plan recommendations Proposal to the administrators, pharmacist interest assessment surveya Interested pharmacist survey (subgroup A),a disinterested pharmacist survey (subgroup B)a Official program announcement, program brochure sent to pharmacists Program slides sent to pharmacists, poster presentation at ASHP Midyear Clinical Meeting, Q and A session with pharmacists Application deadline Inaugural resident matched Poster presentation at Eastern States Conference Best-practices presentation at Veterans Integrated Services Network 4 Conference Program commencement (resident 1) Program commencement (resident 2) Program completion (resident 1)b Program completion (resident 2)b
July 2011 September 2011 November 2011 December 2011
January 2012 March 2012 May 2012 June 2012 July 2012 July 2013 June 2014 June 2015
Each segment of the surveys was completed within two weeks. Anticipated.
a
b
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2023
PRACTICE REPORTS Pharmacy residency program
Eligibility. After taking into account the survey responses and the needs of the institution, eligibility requirements were developed. To be eligible for the Lebanon VAMC nontraditional PGY1 pharmacy residency program, the pharmacist must be a full-time employee with at least one year of service before the program start date. The pharmacist must be able to commit to a two-year residency in addition to a two-year service commitment on completion of the program. The nontraditional program application requirement is similar to that for traditional residency programs. The pharmacist must participate in the ASHP Match as part of the ASHP accreditation standard. The pharmacist must submit a letter of intent, curriculum vitae, and three letters of recommendation. The application deadline for the nontraditional PGY1 program is midJanuary, the same as the application deadline for the traditional PGY1 program at Lebanon VAMC. Pharmacists (employees) who apply for the nontraditional program are not required to submit their transcripts, as these were previously furnished before their hiring. Residency interview and NMS code. Three pharmacists completed the Lebanon VAMC nontraditional program application before the deadline and were interviewed for the inaugural nontraditional PGY1 pharmacy resident position. Application and interview evaluations were entered in the Pharmacy Residency Application Tracker (PRAT), an internally built database used for application storage, point-system scoring, and statistical evaluations. All applicants were required to register in the Match and obtain a unique NMS code. The program obtained a unique NMS code that was specific to the nontraditional program; additional costs were not incurred since the traditional PGY1 pharmacy residency program was registered with NMS. Before submitting the 2024
rank list, the residency advisory committee gathered to discuss the PRAT statistics and compared them with the overall subjective best-fit candidate for the program. Applicants and the RPD were notified of the Match results in March via e-mail from the Match. One pharmacist was matched and began the residency in July 2012 as the inaugural nontraditional PGY1 pharmacy resident at Lebanon VAMC, the second institution to implement the nontraditional program within the Veterans Health Administration. The resident is expected to complete the program in June 2014 and remain committed to the Lebanon VAMC pharmacy service for a minimum of two years thereafter. Accreditation and funding. The Lebanon VAMC PGY1 and PGY2 pharmacy residency programs have been reviewed by the ASHP Commission on Credentialing and accredited by the ASHP Board of Directors. The design and structure of the nontraditional PGY1 program at Lebanon VAMC are equivalent to the traditional PGY1 program and use ASHP tools (e.g., RLS, ResiTrak) to teach and evaluate both traditional and nontraditional residents. While traditional pharmacy residency programs of the Department of Veterans Affairs are centrally funded by the Office of Academic Affiliations, the nontraditional pharmacy residency program does not require an additional funding request. Residents in the nontraditional PGY1 program are paid by the institution at a full pharmacist salary without any revocation or change in their existing health benefits, retirement plan, and leave accruement. Rotation structure. Depending on the individual resident and his or her level of practice experiences, certain learning experiences may be amended and tailored to the resident’s learning needs. For example, an experienced staff pharmacist with extensive inpatient and outpatient pharmacy experience may not be
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
challenged if placed to fulfill the service commitment (staffing) requirement with operational pharmacy services (e.g., inpatient or outpatient prescription processing, verification, consultation, i.v. admixtures). Alternatively, the resident may fulfill the service commitment (staffing) with clinical pharmacy services (e.g., interdisciplinary team rounds, medication therapy management, therapeutic drug monitoring). The nontraditional program rotation structure is based on a 1:1 ratio (residency learning experience:staff work) alternating schedule. At the end of each rotation, the resident is expected to return to staff work for a comparable amount of time that was spent on the residency learning experience. Each required or elective learning experience ranges from four to six weeks. Longitudinal learning experiences may extend up to two years for residents. Nontraditional program residents are familiar with the institution’s operation flow and computer system and may be exempt from the new employee orientation. However, they are required to participate in the residency program orientation. The residency orientation functions as a mean to communicate the program expectations and allow opportunities for all residents to collaborate and support one another as a team early on. Learning experiences. Figures 1 and 2 illustrates the scheduling model for both traditional and nontraditional PGY1 residents at Lebanon VAMC. In order to meet the needs of patient care from an operational standpoint and fulfill the nontraditional resident’s learning outcomes, residency and staff work schedules must be flexible. Lebanon VAMC traditional and nontraditional PGY1 residents have five required and four elective learning experiences. Longitudinal learning experiences include completion of a major residency project, service commitment (staffing), formal response
Select and start residency project
a
ASHP Midyear and project time (2 wk)
ACPE presentation
Required LE 1a (cont.): Management 2 of 2 (2 wk) Inpatient/ outpatient pharmacy training Select ACPE topic (2 wk)
New traditional and nontraditional residents are placed together during residency orientation and management learning experience to help with group cohesiveness. LE = learning experience.
Residency completion Eastern States Conference
Elective LE 4: Hospice palliative care (4 wk) Elective LE 3: Advanced acute care (4 wk) Elective LE 2: Oncology (4 wk) Elective LE 1: Behavioral health (4 wk) Required LE 2: Acute care (6 wk)
Required LE 3: Primary care (4 wk)
Required LE 4: Ambulatory care (6 wk)
Required LE 5: Extended care (6 wk) Required LE 1a: Management 1 of 2 (2 wk)
July
Residency orientationa (2 wk)
May April March Mid-January Through February Mid-November to Mid-January October to Mid-November August and September
Figure 1. Schedule for traditional pharmacy residents.a
to drug information inquiries, review of nonformulary drug requests, and Accreditation Council for Pharmacy Education continuing education. A description of the required learning experiences is provided below. Practice management. This required learning experience allows the resident to participate on the pharmacy management team, which has the overall responsibility to plan, direct, and coordinate comprehensive pharmacy services throughout the medical center. The learning experience is split into two two-week blocks. The first block encompasses the broad aspects of pharmacy administration, such as operations management, pharmacy policy, formulary management systems, and an introduction to general pharmacy practice. The second block focuses on the details of daily operations, including the performance of the pharmacy service and personnel, clinical program development, and fiscal management. Acute care. This required learning experience allows the resident to develop expertise in the treatment of acute conditions commonly encountered in the inpatient internal medicine environment. The resident participates in daily medicine rounds with attending physicians, medical residents, and other health care professionals to ensure that appropriate pharmacotherapy is used in all patients. The resident is expected to participate in the selection of therapy, respond to drug information questions, counsel patients on the use and adverse effects of medications, obtain medication histories, and monitor drug levels to make pharmacokinetic dosing recommendations. The resident will also present a patient case to the pharmacy staff and a lecture to the medical residents and students. Primary care/patient-aligned care team. This required learning experience allows the resident to work as an integral member of the primary care team. The resident serves as a drug
June
PRACTICE REPORTS Pharmacy residency program
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2025
2026
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Elective LE 1: Diabetes (4 wk)
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
August
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Required LE 1a (cont.): Management 2 of 2 (2 wk)
Required LE 2: Primary care (4 wk)
Elective LE 2: Behavioral health (4 wk)
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
Mid-October to Mid-November
ASHP Midyear and project time (2 wk)
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Staffing coverage for nontraditional resident year 2 ASHP Midyear and project time (2 wk)
ACPE presentation
Required LE 3: Extended care (6 wk)
Mid-November to Mid-January
Elective LE 3: Advanced primary care (6 wk)
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Mid-January Through February
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Required LE 4: Acute care (6 wk)
March to Mid-April
Eastern States Conference
Elective LE 4: Clinical program management (4 wk)
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
Mid-April to Mid-May
a
New traditional and nontraditional residents are placed together during residency orientation and management learning experience to help with group cohesiveness. LE = learning experience.
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
Select ACPE topic
Required LE 1a: Management 1 of 2 (2 wk)
Residency orientationa (2 wk)
July
September to Mid-October
Figure 2. Schedule for nontraditional pharmacy residents postgraduate year 2.a
Residency completion
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Select and start residency project
Required LE 5: Ambulatory Care (6 wk)
Mid-May Through June
PRACTICE REPORTS Pharmacy residency program
PRACTICE REPORTS Pharmacy residency program
information consultant to clinicians and provides comprehensive pharmacy services with a strong focus on patient-centered care. The resident will have ample time to educate patients on their conditions as well as the proper use of their medications and devices. Ambulatory care. This required learning experience allows the resident to participate in a pharmacistmanaged cardiovascular-risk-reduction clinic. The clinical pharmacy specialists practice under a broad scope of practice, allowing them to prescribe for, monitor, and follow up with patients with hyperlipidemia, diabetes mellitus, and hypertension. The clinical pharmacy specialists also make pharmacotherapy recommendations to providers for all other primary care diseases. The cardiovascular-risk-reduction clinic is a consultation service used by primary care providers as well as specialists to help high-risk patients who are resistant to standard treatment gain control of their diseases and reach their individual therapeutic goals. The main rotation site is Lebanon VAMC, but there is an option to gain additional experience at one of the community-based outpatient clinics. There are educational opportunities throughout the learning experience, including small-group teaching for veterans and other health care professionals and inservice education programs for allied health care professionals, pharmacists, and primary care providers. Extended care. This required learning experience allows the resident to develop expertise in the treatment of inpatients requiring long-term treatment of chronic illnesses. The resident rounds with the extended care team; by working with physicians and other members of the interdisciplinary team, the resident helps to ensure the appropriate care of veterans. The resident will also be an integral part of the palliative care team. Working jointly with the
palliative care physician, the resident will develop the necessary skills to appropriately manage the palliative care patients at both the inpatient service and the outpatient clinic. In addition, the resident gains a unique experience while working in the weight-management program for veterans. Benefits of the residency. In addition to providing an alternative for applicants to pursue residency training if the traditional route is not feasible, the nontraditional PGY1 residency promotes staff development, advances pharmacy practice, and facilitates pharmacist recruitment and retention. Residency training enables pharmacists to enhance their clinical, preceptorship, and leadership skills; provide the highest level of pharmaceutical care to the patients whom they serve; and practice at the top of their license. Furthermore, implementation of the nontraditional residency program helps to fulfill the residency training requirement supported by ASHP and ACCP and prepare pharmacists to confidently assume clinical responsibilities in the pharmacy practice model. According to the 2010 ACCP White Paper: Rewards and Advancements for Clinical Pharmacists, clinical pharmacists reported work–life balance, a challenging position, and opportunities for professional advancement as the most important factors for career success; financial rewards were not a major motivator.11 The survey conducted at Lebanon VAMC yielded a similar response. Pharmacists who aspire to complete a residency are motivated by career-advancement opportunities, not monetary incentives. Lebanon VAMC currently does not offer any bonus or guarantee a clinical promotion at the end of residency training. However, by completing the nontraditional residency program, the pharmacist would be more qualified for careeradvancement opportunities, such as a new clinical position or vacancies at a
higher grade scale (e.g., clinical pharmacy specialist, clinical coordinator). Challenges of the residency program. Intermittently withdrawing a full-time employee for two (or three) consecutive years could pose multiple challenges. Before implementation of the program, the pharmacy chief or director, the RPD, the immediate pharmacy supervisor, and other affected administrative staff should discuss the return on investment of the nontraditional residency program, identify the potential impact on the pharmacy service line, identify system redesign opportunities, and formulate strategies on how to optimally use the available resources. This unique program is exclusively designed for internal employees. Sustaining the nontraditional program may become difficult when all the pharmacists within the institution have completed residency training or when interest in the nontraditional program has diminished. Administrative challenges secondary to the nontraditional program include generating a fair and balanced schedule for preceptors, pharmacists, and residents (traditional and nontraditional), distributing the workload evenly among staff members, and authorizing overtime or compensatory time as deemed necessary to avoid compromising patient care. Ensuring a smooth transition between each residency and staffing rotation is imperative to help avoid changing the schedule and rearranging assignments at the last minute, which could cause distress among other staff members. The RPD and the immediate pharmacy supervisor must coordinate and communicate with each other in order to operate a successful program. They are also highly encouraged to be cognizant and supportive of the resident as he or she endeavors the dual-role balance in the nontraditional program. The nontraditional pharmacy resident at Lebanon VAMC may not receive overtime or compensatory
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2027
PRACTICE REPORTS Pharmacy residency program
time during his or her residency rotation; however, it may be authorized during the staffing rotation. Residency rotation refers to the time period when the program participant is functioning as a pharmacy resident. Staffing rotation refers to the time period when the program participant is functioning as a pharmacist on staff. Challenges for the resident may include receiving residual distractions from the preceding residency rotation or staffing rotation, resuming the student role and being accustomed to having homework outside of the regular workweek, and learning to simultaneously balance his or her residency, work, and personal life. The resident may not routinely be able to commit additional residency hours due to personal or family obligations. The RPD should define the resident’s role and responsibilities specific to the longitudinal learning experiences during the period when the resident is serving as a pharmacist. The residency and staffing intertwinement could get complicated if the expectation is not clearly established. Lessons learned The development phase of the nontraditional pharmacy residency program relied mostly on the staff survey responses, the limited publications on nontraditional programs, and the extrapolation from traditional programs. A compilation of existing nontraditional pharmacy residency programs is currently not available in the ASHP residency directory. The unofficial list of existing programs (Table 1) may not be all-inclusive. Nontraditional PGY1 or PGY2 programs that did not participate in the Match or publicly announce the existence of their
2028
program were not listed on Table 1. While ASHP offers a plethora of information pertaining to traditional pharmacy residency programs, there is a lack of guidance or recommendations for nontraditional residency programs. Therefore, involving the staff and networking with the RPD are recommended during the design and implementation phases. The nontraditional pharmacy resident at Lebanon VAMC has encountered challenges with time management and task distractions when transitioning from residency to staffing rotation or vice versa. The two pharmacists who did not match with the program in 2012 continued their usual functions in the operational pharmacy services without posing any additional challenges after the Match. The RPD met with the two unmatched pharmacists individually after the release of the Match results. The RPD discussed the strengths and weaknesses of their applications and interviews, assisted in identifying areas of improvement, and helped formulate strategies to enhance their qualification for the following year’s selection. One of the unmatched pharmacists reapplied and was matched in 2013. The Lebanon VAMC expects to graduate its first nontraditional PGY1 resident in June 2014 and its second resident in June 2015. Implementation of the nontraditional residency program has had generally positive outcomes. It showed the staff that administrators and leaders are dedicated to their professional development and career advancement. Decentralizing pharmacy services may be implemented with ease when pharmacists are able to confidently utilize their clinical skills.
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Conclusion A nontraditional PGY1 pharmacy residency program was successfully developed and implemented for pharmacists who aspire to complete residency training and improve their clinical, leadership, and preceptorship skills. References 1. American Society of Health-System Pharmacists. 2015 ASHP Health-System Pharmacy Initiative. www.ashp.org/menu/ PracticePolicy/Initiatives/2015Initiative. aspx (accessed 2012 Jun 23). 2. American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative. www.ashpmedia.org/ppmi/ index.html (accessed 2012 Jun 23). 3. Smith KM, Sorensen T, Conner KA et al. ACCP white paper: value of conducting pharmacy residency training—the organizational perspective. Pharmacotherapy. 2010; 30:490e-510e. 4. Murphy JE, Nappi JM, Bosso JA et al. American College of Clinical Pharmacy’s vision of the future: postgraduate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006; 26:722-33. 5. Main LL, Vlasses PH. Assessing quality in pharmacy education in an era of rapid expansion. J Am Pharm Assoc. 2012; 52:528-34. 6. National Matching Services. ASHP Resident Matching Program. www.natmatch. com/ashprmp/ (accessed 2013 Mar 23). 7. Winegardner ML, Davis SL, Szandzik EG et al. Nontraditional pharmacy residency at a large teaching hospital. Am J HealthSyst Pharm. 2010; 67:366-70. 8. Traynor K. Pharmacists see positives in nontraditional residency programs. Am J Health-Syst Pharm. 2012; 69:632-3. News. 9. Johnson TJ. Pharmacist work force in 2020: implications of requiring residency training for practice. Am J Health-Syst Pharm. 2008; 65:166-70. 10. American Society of Health-System Pharmacists. Residency accreditation. www.ashp.org/menu/Accreditation/ ResidencyAccreditation.aspx (accessed 2012 Jun 23). 11. Goodwin SD, Kane-Gill SL, Ng TM et al. ACCP white paper: rewards and advancements for clinical pharmacists. Pharmacotherapy. 2010; 30:68e-85e.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
PRACTICE REPORTS
Implementation of a nontraditional postgraduate year 1 pharmacy residency program Khenh S. Vong, Kevin A. Koons, and Paul A. Carnes
Scan to access AJHP podcasts
I
An audio interview that supplements the information in this article is available on AJHP’s website at www.ajhp.org/ site/misc/podcasts.xhtml.
n 2003, the American Society of Health-System Pharmacists (ASHP) launched the ASHP Health-System Pharmacy 2015 Initiative with the intent to improve the practice of pharmacy in hospitals and health systems by promoting public health and ensuring that medication use is safe, effective, and evidence based. As pharmacy practice evolved, the Pharmacy Practice Model Initiative (PPMI) was introduced in 2010 and supplanted the ASHP HealthSystem Pharmacy 2015 Initiative.1 The goal of the PPMI is to significantly advance the health and well-being of patients by developing and disseminating a futuristic practice model that supports the most effective use
Purpose. The development and implementation of a nontraditional pharmacy residency program at a Veterans Affairs medical center (VAMC) are described. Summary. The nontraditional pharmacy residency program at Lebanon VAMC was designed in accordance with the ASHP accreditation standard. The residency program was structured to meet staff needs without compromising patient care or significantly affecting the pharmacy services provided. The purpose statement, intended outcomes, and learning goals and objectives of the nontraditional pharmacy residency program were formulated to be equivalent to those of a traditional one-year pharmacy residency program, enabling practicing pharmacists to obtain similar overall learning experiences. The nontraditional residency program at Lebanon VAMC spans two years. The nontraditional program structure is based on a four- to six-week residency learning ex-
of pharmacists as direct patient care providers.2 ASHP and the American College of Clinical Pharmacy (ACCP) advocate residency training as a pre-
Khenh S. Vong, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Veterans Affairs Southern Nevada Healthcare System, North Las Vegas; at the time of writing she was Clinical Pharmacy Specialist, McAllen Outpatient Clinic, Veterans Affairs Texas Valley Coastal Bend Health Care System, McAllen, TX. Kevin A. Koons, Pharm.D., BCPS, is Assistant Chief of Pharmacy; and Paul A. Carnes, Pharm.D., M.S., FACHE, is Chief of Pharmacy, Lebanon Veterans Affairs Medical Center, Lebanon, PA. Address correspondence to Dr. Vong at the Southern Nevada Healthcare System, 6900 North Pecos Road, North Las Vegas, NV 89086 ([email protected]).
perience that alternates with a comparable time in the work schedule. Each required or elective learning experience ranges from four to six weeks. Longitudinal learning experiences may extend up to two years. One pharmacist was matched and began the residency in July 2012 as the inaugural nontraditional postgraduate year 1 (PGY1) pharmacy resident at Lebanon VAMC, the second institution to implement the nontraditional program within the Veterans Health Administration. The resident is expected to complete the program in June 2014 and remain committed to the Lebanon VAMC pharmacy service for a minimum of two years thereafter. Conclusion. A nontraditional PGY1 pharmacy residency program was successfully developed and implemented for pharmacists who aspire to complete residency training and improve their clinical, leadership, and preceptorship skills. Am J Health-Syst Pharm. 2013; 70:2019-28
requisite for pharmacists assuming direct patient care roles.2-4 Resident and pharmacist positions are expected to be more
This project was reviewed and approved as quality assurance or quality improvement in accordance with Lebanon Veterans Affairs Medical Center policy and procedure. This work is the authors’own and does not represent the views or opinions of the Veterans Health Administration. Presented at the ASHP Midyear Clinical Meeting in New Orleans, LA, December 7, 2011, and the Eastern States Conference in Hershey, PA, May 2, 2012. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130025
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2019
PRACTICE REPORTS Pharmacy residency program
competitive based on the projected number of pharmacy graduates reaching approximately 13,800 by 2014, an increase of more than 2,300 new graduates compared with 2011.5 Data from the 2013 ASHP Resident Matching Program (the “Match”) revealed that a total of 4,928 applicants enrolled in the Match and that 2,694 positions were offered in traditional and nontraditional postgraduate year 1 (PGY1) pharmacy residency programs.6 Of the enrolled applicants, 3,933 (80%) participated in the Match. Of these, 2,495 (63%) were matched. The 1,438 unmatched applicants had to face the “postmatch scramble” for the remaining 199 unfilled residency positions (7%) or obtain a pharmacist position without residency training. In an effort to provide residency training for pharmacists on staff, various traditional PGY1 and postgraduate year 2 (PGY2) pharmacy residency programs have expanded their programs by extending the training period over two to three years. This extension is known as a nontraditional pharmacy residency program, a strategy that enables practicing pharmacists to fulfill their current duties while completing residency training on a part-time basis. Published information regarding these types of programs is limited. The implementation of a nontraditional pharmacy residency could be valuable for the recruitment, retention, and development of staff.7 This article describes the development and implementation of a nontraditional pharmacy residency program. Background The Lebanon Veterans Affairs Medical Center (VAMC), a teaching hospital in Lebanon, Pennsylvania, with approximately 250 beds, provides a wide range of patient care services using state-of-the-art technology guided by ongoing education and research. Lebanon VAMC has six 2020
community-based outpatient clinics located in Camp Hill, York, Reading, Lancaster, Pottsville, and Frackville, Pennsylvania. Care is available to over 174,000 veterans from nine counties in south central Pennsylvania. An outreach clinic is also available at Fort Indiantown Gap, and administrative support is given to two veterans centers in nearby Harrisburg and Lancaster and a national cemetery in Fort Indiantown Gap. The department of pharmacy supports 32 pharmacist full-time equivalents, 1 VALOR (Veterans Affairs learning opportunities residency) intern, 3 PGY1 residents (traditional 12-month program), 1 PGY2 ambulatory care resident, and 1 PGY2 health-system pharmacy administration resident. Both PGY1 and PGY2 pharmacy residency programs are accredited by ASHP. Details regarding patient care services and residency programs are available from the Lebanon VAMC website (www.lebanon.va.gov). Pharmacy practice model. The pharmacy practice model at Lebanon VAMC includes both clinical pharmacy specialists and clinical pharmacists. Pharmacists use a computerized patient record system and Veterans Integrated System Technology Architecture to review patient medical records, document progress notes, enter orders, process prescriptions, and perform other numerous functions. Clinical pharmacy specialists provide direct patient care and function under an approved scope of practice with prescribing privileges. Clinical pharmacy services are available in acute care, ambulatory care (cardiovascular-risk-reduction clinic and diabetes clinic), behavioral health, extended care, hospice and palliative care, oncology (chemotherapy and epoetin clinic), primary care, and other patient care settings. Clinical pharmacy specialists are required to spend approximately 10% of their workweek in operational pharmacy services to maintain com-
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
petencies in distributive functions and to assist with establishing good rapport intradepartmentally and interdepartmentally. Clinical pharmacy specialists also provide ongoing inservice education and serve as preceptors to pharmacy students and residents. Clinical pharmacists process medication orders and dispense prescriptions; provide and document medication consultations and relevant findings in the patient’s medical record; review drug–drug, drug–food, and drug–allergy interactions; and perform other clinical activities (e.g., reconcile medications, review home-based primary care charts, attend inpatient rounds, serve as a preceptor to pharmacy students or residents). Clinical pharmacists are cross-trained and have rotating schedules in both inpatient and outpatient operational pharmacy services. Over 3000 outpatient prescriptions are processed daily at the pharmacy at Lebanon VAMC, many of which are filled by the offsite consolidated mail outpatient pharmacy. Clinical pharmacists may also spend approximately 10% of their workweek performing other special assignments. Under reasonable circumstances, a compressed work schedule may be approved to better facilitate pharmacists’ work–life balance. Pharmacy residents rotate through various learning experiences (i.e., direct patient care in clinical pharmacy services, operational services in the inpatient or outpatient pharmacy, and administrative pharmacy services) during their residency. The Lebanon VAMC pharmacy vision is to provide the highestquality, value-added pharmaceutical care to veterans. Strategic plan survey. In 2011, strategic plan surveys were conducted to align the pharmacy department’s mission and vision. The results of the surveys were tabulated and prompted the creation of six goals and numerous objectives, which are listed below. Creating a
PRACTICE REPORTS Pharmacy residency program
nontraditional pharmacy residency training opportunity for pharmacists was one of the objectives set forth to support most of these goals:
Table 1.
List of Nontraditional Pharmacy Residency Programsa Institution
1. Create a work environment that is professional, pleasant, fair, and unified while maintaining a favorable work–life balance for employees. 2. Develop strategies to improve recruitment of new staff, ensure retention of current staff, and afford opportunities for upward mobility. 3. Provide a pharmacy service that is perceived as timely, effective, comprehensive, and of necessity by all of pharmacy’s customers. 4. Develop a work force with the technical and clinical skills to meet the needs of a changing pharmacy practice. 5. Be known as a leader of pharmacy practice in our region and ensure a positive image of the department locally. 6. Effectively employ technology that optimizes efficient distributive and clinical services to allow ideal patient– pharmacist interactions.
Nontraditional pharmacy residency program A traditional pharmacy residency is a continuous, 12-month, postgraduate advanced training program. It typically begins in July and ends the following June. Although there is no established definition for a nontraditional pharmacy residency, it is presumed to be an intermittent 24–36-month postgraduate advanced training program based on the existing nontraditional pharmacy residency. Institutions with established nontraditional pharmacy residencies are listed in Table 1.6,8 The nontraditional program targets pharmacists in the work force who have not completed residency training. The commencement and completion dates of the residency are based on the term agreed upon by the institution, the residency program director (RPD), and the resident (employee). Salary and postresidency service commitment term vary by institution.7,8
Avera McKennan Hospital and University Health Center (Sioux Falls, SD) Hennepin County Medical Center (Minneapolis, MN) Henry Ford Hospital (Detroit, MI) Johns Hopkins Hospital (Baltimore, MD) Karmanos Cancer Center (Detroit, MI) Kern Medical Center (Bakersfield, CA) Lebanon Veterans Affairs Medical Center (Lebanon, PA) Memorial Regional Hospital (Hollywood, FL) Monroe Carell Jr. Children’s Hospital at Vanderbilt (Nashville, TN) Roudebush Veterans Affairs Medical Center (Indianapolis, IN) St. Joseph’s/Candler Hospital (Savannah, GA)
Program Type
Program Length (yr)
PGY1
2
PGY1
2–3
PGY1 and PGY2— Critical Care PGY1 PGY2—Oncology PGY1 PGY1
3 2 2–3 3 2
PGY1
2
PGY1
2
PGY1
2
PGY1
3
a List includes programs that are listed as participating in the ASHP Residency Matching Program or that have publicly announced the establishment of their program. PGY1 = postgraduate year 1, PGY2 = postgraduate year 2.
Residents in nontraditional pharmacy residencies are provided opportunities to enhance their competence in patient-centered care and operational pharmacy services and to further develop their leadership skills by refining their problemsolving strategies, strengthening their professional values and attitudes, and advancing their clinical judgment. Because the nontraditional residency is an extension of the traditional pharmacy residency program, it does not require supplemental ASHP accreditation survey or review. However, all PGY1 and PGY2 programs in precandidate, candidate, preliminary accreditation, conditional accreditation, or accredited status must participate in the Match conducted by ASHP, meaning that residents in nontraditional programs are required to participate in the Match. The nontraditional residency is intended to be equivalent to the traditional residency program and therefore must consist of similar Res-
idency Learning System (RLS) outcomes, goals, and objectives. Ongoing evaluation and assessment of the resident’s progress, documentation of learning experiences and completion, and resident self-evaluation are important tools that must be included in the program. The evaluation process for residents in nontraditional programs is the same as that for residents in traditional programs. At the conclusion of every learning experience and at least quarterly for longitudinal experiences, residents will evaluate the preceptor and learning experience using ResiTrak (McCreadie Group, Ann Arbor, MI). Residents, preceptors, and the RPD will meet to discuss their evaluations and provide constructive feedback. The resident’s residency performance evaluation is independent of his or her pharmacist staffing performance appraisals. Similar to residents in traditional programs, residents in nontraditional programs will be held responsible and accountable
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2021
PRACTICE REPORTS Pharmacy residency program
for acquiring the following PGY1 pharmacy residency outcome competencies: managing and improving the medication-use process; providing evidence-based, patient-centered medication therapy management with interdisciplinary teams; exercising leadership and practice management; demonstrating project management skills; providing medication and practice-related education or training; and utilizing medical informatics. In addition to completing various required and elective learning experiences, nontraditional pharmacy program residents must complete a major residency project. They are strongly encouraged to present the results of the residency project at a national meeting and are required to complete a formal manuscript of the completed project in a form suitable for publication in an appropriate professional journal. ASHP is the sole accrediting body for pharmacy residencies in the United States.9 A full review of residency accreditation requirements and program design elements are available at ASHP’s website.10 Development and implementation of the nontraditional PGY1 pharmacy residency Based on the Lebanon VAMC pharmacy department’s 2011 strategic plan recommendations, the goals of nontraditional residency program implementation included promoting staff development, advancing pharmacy practice, and facilitating pharmacy recruitment and retention. After obtaining administrator approval for the nontraditional pharmacy residency, the program was designed in accordance with the ASHP accreditation standard. The residency program was structured to fit staff needs without compromising patient care or significantly affecting the pharmacy services provided. The purpose statement, intended outcomes, and learning goals and objectives of the nontraditional 2022
pharmacy residency program were formulated to be equivalent to those of a traditional one-year pharmacy residency program, enabling practicing pharmacists to obtain similar overall learning experiences. Survey of pharmacists. In July 2011, an introduction to the nontraditional program was e-mailed to all 32 pharmacists at Lebanon VAMC. This e-mail contained a synopsis of the program and asked, “Would you be interested in applying for a nontraditional PGY1 pharmacy residency program if the opportunity existed?” A voting button with four answer choices was made available as A. Yes. I am interested. B. Maybe. I would like to receive more information. C. No. I am not interested. D. No. I have previously completed a PGY1 pharmacy residency.
Results were tabulated within two weeks. Eight pharmacists voted that they were either interested or may be interested in the nontraditional program, 8 pharmacists were not interested in the nontraditional program, 12 pharmacists indicated that they had previously completed a residency, and 4 pharmacists did not respond to this survey. Based on each individual’s response, corresponding surveys were generated and sent to subgroup A (individuals who indicated that they were either interested or maybe interested in the nontraditional program) and subgroup B (individuals not interested in the nontraditional program). No corresponding surveys were sent to subgroup C (individuals who completed a residency or did not cast their vote). Surveys of subgroups A and B allowed pharmacists to answer each question by selecting the applicable provided answer options, free text their answers, and provide additional comments or recommendations. Corresponding surveys were completed within two weeks.
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Survey of subgroup A. This survey assessed pharmacists’ preferences for the nontraditional PGY1 residency’s design and structure, their expectations of the program, and any concerns pharmacists may have related to the program. Pharmacists were asked to 1. List and rank preferences in the nontraditional program’s duration (e.g., two versus three years), program rotation structure (e.g., 1:1 versus 1:2 alternating residency and staff work rotations), and months for program commencement and completion (e.g., July through June [residency year] versus January through December [calendar year]). 2. List and rank aspirations for pursuing a nontraditional residency (e.g., increase salary; obtain clinical or management position; improve clinical, leadership, or preceptorship skills; improve task efficiency in current position; increase clinical responsibilities). 3. List and select expectations upon completion of nontraditional residency (e.g., increase salary; be promoted to a clinical position; obtain a scope of practice with prescribing privileges; maintain current position with improved clinical, leadership, or preceptorship skills; prepare for board-certification examinations). 4. List the learning experiences in which they are most interested. 5. List and select the desired practice environment after residency completion. 6. List and select the concerns they have about the residency (e.g., time management and ability to keep up with residency workload, prioritizing assignments from preceptors and staffing responsibilities, changing mindset and alternating roles from a practitioner to a resident, receptiveness to critique from preceptors [colleagues], performance evaluation, residency and staffing schedule imbalance, ability to fulfill all requirements and complete the program, program and contract commitment, restrictions
PRACTICE REPORTS Pharmacy residency program
on overtime or compensatory time, no monetary incentives, no clinical promotions).
Survey of subgroup B. This survey assessed pharmacists’ reasons for their disinterest in the nontraditional program and any potential factors that may encourage them to reconsider the nontraditional residency in the future. Pharmacists were asked to 1. List and select reasons for not being interested in the nontraditional PGY1 program (e.g., satisfied with current position, retirement within 5–10 years, possible relocation within 3 years, personal or family responsibilities, no financial incentives, extended residency program duration, residency program workload, residency program hours, inadequate baseline clinical skills, questionable competency to complete program). 2. List and select factors that would make you reconsider the nontraditional PGY1 program (e.g., financial incentives, shortened residency program duration, no contract obligations).
Of the eight recipients of the subgroup A survey, seven responded (87.5%); all eight survey recipients of the survey in subgroup B responded (100%). Most of the respondents in subgroup A were interested in a twoyear program that begins in July as opposed to a three-year program or a program that begins in January. A residency learning experience:staff work ratio of 1:1 was preferred by most respondents (e.g., six weeks’ residency learning experience alternating with six weeks’ staff work). Improving clinical, leadership, preceptorship skills; improving task efficiency; and increasing clinical responsibilities were among the top aspirations selected by respondents. Monetary incentives were not the primary reasons for considering the nontraditional program. The most common concerns were associated with time management.
In subgroup B, six respondents (75%) indicated that they were satisfied with their current positions. However, they may reconsider the nontraditional program in the future if there are financial incentives, there is no service commitment on completion of the program, or the duration of the program is shortened. Recruitment and marketing materials. The development of and recruitment for the nontraditional PGY1 program were achieved in approximately six months. Table 2 provides the development timeline and the associated residency program activities. Pharmacists who have not completed a residency may not be fully aware of what a residency entails and the preparation that is required. Meeting announcements, program brochures, and PowerPoint presentations, as well as the initial surveys, served not only as marketing tools but as informational resources
to ensure that all pharmacists at Lebanon VAMC fully understood the benefits and challenges of completing a residency. The brochure for the nontraditional residency program contained general program information; an overview and example of the rotation schedule; information about learning experiences, benefits, eligibility, and application requirements and deadlines; the program’s National Matching Service (NMS) code; contact information; and links to the Match and the existing Lebanon VAMC PGY1 pharmacy residency program brochure. The PowerPoint presentation contained supplemental information to assist pharmacists with preparing for their residency application and interview. In addition, a Q and A session was held with the pharmacists to provide any needed clarifications and information that would support decision-making.
Table 2.
Nontraditional Pharmacy Residency Program Development Timeline and Activities at Lebanon Veterans Affairs Medical Center Date
Activities
July 2010–June 2011
Pharmacy service strategic plan surveys,a formulation of strategic plan recommendations Proposal to the administrators, pharmacist interest assessment surveya Interested pharmacist survey (subgroup A),a disinterested pharmacist survey (subgroup B)a Official program announcement, program brochure sent to pharmacists Program slides sent to pharmacists, poster presentation at ASHP Midyear Clinical Meeting, Q and A session with pharmacists Application deadline Inaugural resident matched Poster presentation at Eastern States Conference Best-practices presentation at Veterans Integrated Services Network 4 Conference Program commencement (resident 1) Program commencement (resident 2) Program completion (resident 1)b Program completion (resident 2)b
July 2011 September 2011 November 2011 December 2011
January 2012 March 2012 May 2012 June 2012 July 2012 July 2013 June 2014 June 2015
Each segment of the surveys was completed within two weeks. Anticipated.
a
b
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2023
PRACTICE REPORTS Pharmacy residency program
Eligibility. After taking into account the survey responses and the needs of the institution, eligibility requirements were developed. To be eligible for the Lebanon VAMC nontraditional PGY1 pharmacy residency program, the pharmacist must be a full-time employee with at least one year of service before the program start date. The pharmacist must be able to commit to a two-year residency in addition to a two-year service commitment on completion of the program. The nontraditional program application requirement is similar to that for traditional residency programs. The pharmacist must participate in the ASHP Match as part of the ASHP accreditation standard. The pharmacist must submit a letter of intent, curriculum vitae, and three letters of recommendation. The application deadline for the nontraditional PGY1 program is midJanuary, the same as the application deadline for the traditional PGY1 program at Lebanon VAMC. Pharmacists (employees) who apply for the nontraditional program are not required to submit their transcripts, as these were previously furnished before their hiring. Residency interview and NMS code. Three pharmacists completed the Lebanon VAMC nontraditional program application before the deadline and were interviewed for the inaugural nontraditional PGY1 pharmacy resident position. Application and interview evaluations were entered in the Pharmacy Residency Application Tracker (PRAT), an internally built database used for application storage, point-system scoring, and statistical evaluations. All applicants were required to register in the Match and obtain a unique NMS code. The program obtained a unique NMS code that was specific to the nontraditional program; additional costs were not incurred since the traditional PGY1 pharmacy residency program was registered with NMS. Before submitting the 2024
rank list, the residency advisory committee gathered to discuss the PRAT statistics and compared them with the overall subjective best-fit candidate for the program. Applicants and the RPD were notified of the Match results in March via e-mail from the Match. One pharmacist was matched and began the residency in July 2012 as the inaugural nontraditional PGY1 pharmacy resident at Lebanon VAMC, the second institution to implement the nontraditional program within the Veterans Health Administration. The resident is expected to complete the program in June 2014 and remain committed to the Lebanon VAMC pharmacy service for a minimum of two years thereafter. Accreditation and funding. The Lebanon VAMC PGY1 and PGY2 pharmacy residency programs have been reviewed by the ASHP Commission on Credentialing and accredited by the ASHP Board of Directors. The design and structure of the nontraditional PGY1 program at Lebanon VAMC are equivalent to the traditional PGY1 program and use ASHP tools (e.g., RLS, ResiTrak) to teach and evaluate both traditional and nontraditional residents. While traditional pharmacy residency programs of the Department of Veterans Affairs are centrally funded by the Office of Academic Affiliations, the nontraditional pharmacy residency program does not require an additional funding request. Residents in the nontraditional PGY1 program are paid by the institution at a full pharmacist salary without any revocation or change in their existing health benefits, retirement plan, and leave accruement. Rotation structure. Depending on the individual resident and his or her level of practice experiences, certain learning experiences may be amended and tailored to the resident’s learning needs. For example, an experienced staff pharmacist with extensive inpatient and outpatient pharmacy experience may not be
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
challenged if placed to fulfill the service commitment (staffing) requirement with operational pharmacy services (e.g., inpatient or outpatient prescription processing, verification, consultation, i.v. admixtures). Alternatively, the resident may fulfill the service commitment (staffing) with clinical pharmacy services (e.g., interdisciplinary team rounds, medication therapy management, therapeutic drug monitoring). The nontraditional program rotation structure is based on a 1:1 ratio (residency learning experience:staff work) alternating schedule. At the end of each rotation, the resident is expected to return to staff work for a comparable amount of time that was spent on the residency learning experience. Each required or elective learning experience ranges from four to six weeks. Longitudinal learning experiences may extend up to two years for residents. Nontraditional program residents are familiar with the institution’s operation flow and computer system and may be exempt from the new employee orientation. However, they are required to participate in the residency program orientation. The residency orientation functions as a mean to communicate the program expectations and allow opportunities for all residents to collaborate and support one another as a team early on. Learning experiences. Figures 1 and 2 illustrates the scheduling model for both traditional and nontraditional PGY1 residents at Lebanon VAMC. In order to meet the needs of patient care from an operational standpoint and fulfill the nontraditional resident’s learning outcomes, residency and staff work schedules must be flexible. Lebanon VAMC traditional and nontraditional PGY1 residents have five required and four elective learning experiences. Longitudinal learning experiences include completion of a major residency project, service commitment (staffing), formal response
Select and start residency project
a
ASHP Midyear and project time (2 wk)
ACPE presentation
Required LE 1a (cont.): Management 2 of 2 (2 wk) Inpatient/ outpatient pharmacy training Select ACPE topic (2 wk)
New traditional and nontraditional residents are placed together during residency orientation and management learning experience to help with group cohesiveness. LE = learning experience.
Residency completion Eastern States Conference
Elective LE 4: Hospice palliative care (4 wk) Elective LE 3: Advanced acute care (4 wk) Elective LE 2: Oncology (4 wk) Elective LE 1: Behavioral health (4 wk) Required LE 2: Acute care (6 wk)
Required LE 3: Primary care (4 wk)
Required LE 4: Ambulatory care (6 wk)
Required LE 5: Extended care (6 wk) Required LE 1a: Management 1 of 2 (2 wk)
July
Residency orientationa (2 wk)
May April March Mid-January Through February Mid-November to Mid-January October to Mid-November August and September
Figure 1. Schedule for traditional pharmacy residents.a
to drug information inquiries, review of nonformulary drug requests, and Accreditation Council for Pharmacy Education continuing education. A description of the required learning experiences is provided below. Practice management. This required learning experience allows the resident to participate on the pharmacy management team, which has the overall responsibility to plan, direct, and coordinate comprehensive pharmacy services throughout the medical center. The learning experience is split into two two-week blocks. The first block encompasses the broad aspects of pharmacy administration, such as operations management, pharmacy policy, formulary management systems, and an introduction to general pharmacy practice. The second block focuses on the details of daily operations, including the performance of the pharmacy service and personnel, clinical program development, and fiscal management. Acute care. This required learning experience allows the resident to develop expertise in the treatment of acute conditions commonly encountered in the inpatient internal medicine environment. The resident participates in daily medicine rounds with attending physicians, medical residents, and other health care professionals to ensure that appropriate pharmacotherapy is used in all patients. The resident is expected to participate in the selection of therapy, respond to drug information questions, counsel patients on the use and adverse effects of medications, obtain medication histories, and monitor drug levels to make pharmacokinetic dosing recommendations. The resident will also present a patient case to the pharmacy staff and a lecture to the medical residents and students. Primary care/patient-aligned care team. This required learning experience allows the resident to work as an integral member of the primary care team. The resident serves as a drug
June
PRACTICE REPORTS Pharmacy residency program
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2025
2026
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Elective LE 1: Diabetes (4 wk)
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
August
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Required LE 1a (cont.): Management 2 of 2 (2 wk)
Required LE 2: Primary care (4 wk)
Elective LE 2: Behavioral health (4 wk)
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
Mid-October to Mid-November
ASHP Midyear and project time (2 wk)
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Staffing coverage for nontraditional resident year 2 ASHP Midyear and project time (2 wk)
ACPE presentation
Required LE 3: Extended care (6 wk)
Mid-November to Mid-January
Elective LE 3: Advanced primary care (6 wk)
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Mid-January Through February
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Required LE 4: Acute care (6 wk)
March to Mid-April
Eastern States Conference
Elective LE 4: Clinical program management (4 wk)
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
Mid-April to Mid-May
a
New traditional and nontraditional residents are placed together during residency orientation and management learning experience to help with group cohesiveness. LE = learning experience.
Inpatient/ outpatient pharmacy staffing rotation (4 wk)
Select ACPE topic
Required LE 1a: Management 1 of 2 (2 wk)
Residency orientationa (2 wk)
July
September to Mid-October
Figure 2. Schedule for nontraditional pharmacy residents postgraduate year 2.a
Residency completion
Inpatient/ outpatient pharmacy staffing rotation (6 wk)
Select and start residency project
Required LE 5: Ambulatory Care (6 wk)
Mid-May Through June
PRACTICE REPORTS Pharmacy residency program
PRACTICE REPORTS Pharmacy residency program
information consultant to clinicians and provides comprehensive pharmacy services with a strong focus on patient-centered care. The resident will have ample time to educate patients on their conditions as well as the proper use of their medications and devices. Ambulatory care. This required learning experience allows the resident to participate in a pharmacistmanaged cardiovascular-risk-reduction clinic. The clinical pharmacy specialists practice under a broad scope of practice, allowing them to prescribe for, monitor, and follow up with patients with hyperlipidemia, diabetes mellitus, and hypertension. The clinical pharmacy specialists also make pharmacotherapy recommendations to providers for all other primary care diseases. The cardiovascular-risk-reduction clinic is a consultation service used by primary care providers as well as specialists to help high-risk patients who are resistant to standard treatment gain control of their diseases and reach their individual therapeutic goals. The main rotation site is Lebanon VAMC, but there is an option to gain additional experience at one of the community-based outpatient clinics. There are educational opportunities throughout the learning experience, including small-group teaching for veterans and other health care professionals and inservice education programs for allied health care professionals, pharmacists, and primary care providers. Extended care. This required learning experience allows the resident to develop expertise in the treatment of inpatients requiring long-term treatment of chronic illnesses. The resident rounds with the extended care team; by working with physicians and other members of the interdisciplinary team, the resident helps to ensure the appropriate care of veterans. The resident will also be an integral part of the palliative care team. Working jointly with the
palliative care physician, the resident will develop the necessary skills to appropriately manage the palliative care patients at both the inpatient service and the outpatient clinic. In addition, the resident gains a unique experience while working in the weight-management program for veterans. Benefits of the residency. In addition to providing an alternative for applicants to pursue residency training if the traditional route is not feasible, the nontraditional PGY1 residency promotes staff development, advances pharmacy practice, and facilitates pharmacist recruitment and retention. Residency training enables pharmacists to enhance their clinical, preceptorship, and leadership skills; provide the highest level of pharmaceutical care to the patients whom they serve; and practice at the top of their license. Furthermore, implementation of the nontraditional residency program helps to fulfill the residency training requirement supported by ASHP and ACCP and prepare pharmacists to confidently assume clinical responsibilities in the pharmacy practice model. According to the 2010 ACCP White Paper: Rewards and Advancements for Clinical Pharmacists, clinical pharmacists reported work–life balance, a challenging position, and opportunities for professional advancement as the most important factors for career success; financial rewards were not a major motivator.11 The survey conducted at Lebanon VAMC yielded a similar response. Pharmacists who aspire to complete a residency are motivated by career-advancement opportunities, not monetary incentives. Lebanon VAMC currently does not offer any bonus or guarantee a clinical promotion at the end of residency training. However, by completing the nontraditional residency program, the pharmacist would be more qualified for careeradvancement opportunities, such as a new clinical position or vacancies at a
higher grade scale (e.g., clinical pharmacy specialist, clinical coordinator). Challenges of the residency program. Intermittently withdrawing a full-time employee for two (or three) consecutive years could pose multiple challenges. Before implementation of the program, the pharmacy chief or director, the RPD, the immediate pharmacy supervisor, and other affected administrative staff should discuss the return on investment of the nontraditional residency program, identify the potential impact on the pharmacy service line, identify system redesign opportunities, and formulate strategies on how to optimally use the available resources. This unique program is exclusively designed for internal employees. Sustaining the nontraditional program may become difficult when all the pharmacists within the institution have completed residency training or when interest in the nontraditional program has diminished. Administrative challenges secondary to the nontraditional program include generating a fair and balanced schedule for preceptors, pharmacists, and residents (traditional and nontraditional), distributing the workload evenly among staff members, and authorizing overtime or compensatory time as deemed necessary to avoid compromising patient care. Ensuring a smooth transition between each residency and staffing rotation is imperative to help avoid changing the schedule and rearranging assignments at the last minute, which could cause distress among other staff members. The RPD and the immediate pharmacy supervisor must coordinate and communicate with each other in order to operate a successful program. They are also highly encouraged to be cognizant and supportive of the resident as he or she endeavors the dual-role balance in the nontraditional program. The nontraditional pharmacy resident at Lebanon VAMC may not receive overtime or compensatory
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
2027
PRACTICE REPORTS Pharmacy residency program
time during his or her residency rotation; however, it may be authorized during the staffing rotation. Residency rotation refers to the time period when the program participant is functioning as a pharmacy resident. Staffing rotation refers to the time period when the program participant is functioning as a pharmacist on staff. Challenges for the resident may include receiving residual distractions from the preceding residency rotation or staffing rotation, resuming the student role and being accustomed to having homework outside of the regular workweek, and learning to simultaneously balance his or her residency, work, and personal life. The resident may not routinely be able to commit additional residency hours due to personal or family obligations. The RPD should define the resident’s role and responsibilities specific to the longitudinal learning experiences during the period when the resident is serving as a pharmacist. The residency and staffing intertwinement could get complicated if the expectation is not clearly established. Lessons learned The development phase of the nontraditional pharmacy residency program relied mostly on the staff survey responses, the limited publications on nontraditional programs, and the extrapolation from traditional programs. A compilation of existing nontraditional pharmacy residency programs is currently not available in the ASHP residency directory. The unofficial list of existing programs (Table 1) may not be all-inclusive. Nontraditional PGY1 or PGY2 programs that did not participate in the Match or publicly announce the existence of their
2028
program were not listed on Table 1. While ASHP offers a plethora of information pertaining to traditional pharmacy residency programs, there is a lack of guidance or recommendations for nontraditional residency programs. Therefore, involving the staff and networking with the RPD are recommended during the design and implementation phases. The nontraditional pharmacy resident at Lebanon VAMC has encountered challenges with time management and task distractions when transitioning from residency to staffing rotation or vice versa. The two pharmacists who did not match with the program in 2012 continued their usual functions in the operational pharmacy services without posing any additional challenges after the Match. The RPD met with the two unmatched pharmacists individually after the release of the Match results. The RPD discussed the strengths and weaknesses of their applications and interviews, assisted in identifying areas of improvement, and helped formulate strategies to enhance their qualification for the following year’s selection. One of the unmatched pharmacists reapplied and was matched in 2013. The Lebanon VAMC expects to graduate its first nontraditional PGY1 resident in June 2014 and its second resident in June 2015. Implementation of the nontraditional residency program has had generally positive outcomes. It showed the staff that administrators and leaders are dedicated to their professional development and career advancement. Decentralizing pharmacy services may be implemented with ease when pharmacists are able to confidently utilize their clinical skills.
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Conclusion A nontraditional PGY1 pharmacy residency program was successfully developed and implemented for pharmacists who aspire to complete residency training and improve their clinical, leadership, and preceptorship skills. References 1. American Society of Health-System Pharmacists. 2015 ASHP Health-System Pharmacy Initiative. www.ashp.org/menu/ PracticePolicy/Initiatives/2015Initiative. aspx (accessed 2012 Jun 23). 2. American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative. www.ashpmedia.org/ppmi/ index.html (accessed 2012 Jun 23). 3. Smith KM, Sorensen T, Conner KA et al. ACCP white paper: value of conducting pharmacy residency training—the organizational perspective. Pharmacotherapy. 2010; 30:490e-510e. 4. Murphy JE, Nappi JM, Bosso JA et al. American College of Clinical Pharmacy’s vision of the future: postgraduate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006; 26:722-33. 5. Main LL, Vlasses PH. Assessing quality in pharmacy education in an era of rapid expansion. J Am Pharm Assoc. 2012; 52:528-34. 6. National Matching Services. ASHP Resident Matching Program. www.natmatch. com/ashprmp/ (accessed 2013 Mar 23). 7. Winegardner ML, Davis SL, Szandzik EG et al. Nontraditional pharmacy residency at a large teaching hospital. Am J HealthSyst Pharm. 2010; 67:366-70. 8. Traynor K. Pharmacists see positives in nontraditional residency programs. Am J Health-Syst Pharm. 2012; 69:632-3. News. 9. Johnson TJ. Pharmacist work force in 2020: implications of requiring residency training for practice. Am J Health-Syst Pharm. 2008; 65:166-70. 10. American Society of Health-System Pharmacists. Residency accreditation. www.ashp.org/menu/Accreditation/ ResidencyAccreditation.aspx (accessed 2012 Jun 23). 11. Goodwin SD, Kane-Gill SL, Ng TM et al. ACCP white paper: rewards and advancements for clinical pharmacists. Pharmacotherapy. 2010; 30:68e-85e.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
