Hosp Pharm 2013;48(5):351–353 2013 Ó Thomas Land Publishers, Inc. www.thomasland.com doi: 10.1310/hpj4805-351
Guest Editorial Pharmacy Patient Bill of Rights: Practice Advancement From the Patient Perspective Jeff Little, PharmD, MPH, BCPS,p and Scott Mark, PharmD, MS, MEd, MPH, MBA, FASHP, FACHE, FABC†
I
t can be said that the role of the health care professional is to protect the public from that which they cannot protect themselves. While this concept is somewhat abstract, it is a useful exercise to further delineate the protections afforded by health care professionals. The risk points in the health care system and corresponding protections required by those risk points will vary by profession and by practice site. This exercise can then lead to a profession- and site-specific patient bill of rights. This bill of rights can be used to guide future decisions to ensure that all decisions are made with the best interests of the patients in mind. PHARMACY PATIENT BILL OF RIGHTS As with all licensed professions, practicing pharmacy is not a right, it is a privilege. This privilege is granted by the people of the state that issues the license. In return, the public asks for the type of protection described in the introduction. Keeping this concept in mind, pharmacies can develop a pharmacy patient bill of rights. The bill of rights is written from the point of view of the patient. This seemingly small point is actually crucial to bring home the point that everything that the health system pharmacist does needs to be viewed from the perspective of the patient. The items on the bill of rights may seem self-explanatory; however, each point is worthy of discussion. 1. I have a right to have only indicated medications ordered for and administered to me. Before exploring the downstream effects of this right, there needs to be some discussion of what is an indicated medication. Criteria used to determine whether a medication is indicated include the patient’s diagnosis, physical characteristics, past medical history, and level of care (acuity) and the medication’s relative cost-effectiveness. Given that understanding, the pharmacy department must then decide how to position itself
to make sure that this right is not violated. One thing that becomes clear is that the pharmacy must know as much about the patient as possible. Any opportunity to have a pharmacist participate in patient care rounds should be taken advantage of. Although the benefits of pharmacist participation in these rounds have been well established,1,2 many departments may view the benefits as intervention-based. That is, the pharmacist is there to intervene and make recommendations. It is true that pharmacists can improve patient care by making recommendations on rounds, but this does not mean that if a pharmacist does not make a recommendation on rounds, then there was no benefit to the patient. Going on rounds provides the pharmacist access to knowledge about the patient that may otherwise be hard to discover. Another thing that becomes clear when viewed from the perspective of the patient is that this information must be utilized. The pharmacist who knows the most about the patient is in the best position to ensure that the patient gets the indicated medications ordered and administered. Therefore, this right can help drive a pharmacy department to integrate the rounding pharmacist into the distributive process (eg, verifying orders if the hospital has a computerized prescriber order entry system). 2. I have the right to a safe medication process that incorporates the ‘‘5 Rights.’’ The ‘‘5 Rights’’ (the right patient, the right drug, the right dose, the right route, the right time) are familiar to hospital workers, because they deal with medication administration. When viewed from the perspective of the patient, it becomes clear that the pharmacy department can increase the ability of the person who administers the medication to satisfy the 5 Rights. Many pharmacy department decisions will have downstream effects on the ability to ensure everything is correct regarding the medication. Automation, packaging,
*Assistant Director of Pharmacy, Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; †Director, Huron Healthcare Consulting Group, Chicago, Illinois
Hospital Pharmacy
351
Guest Editorial
label code, clinical decision support, drug nomenclature, and so on can impact the likelihood that the person administering the medication is able to do so as accurately as possible. Therefore, the involvement of the people who administer medications in these decisions is a necessity. Additionally, the pharmacists who are physically closest to the patient are also physically closest to medication administration processes. Therefore, they are in the best position to help ensure that the 5 Rights are met. To do this, these pharmacists must have active knowledge of the pharmacy department’s distribution process. Separating the direct patient care and distributive functions of pharmacists interferes with their ability to promote the 5 Rights and therefore goes against this concept. This leads to discussion of the organization’s culture. Current recommendations are for institutions to operate within a Just Culture.3 Recent publications from the Institute for Safe Medication Practices regarding Just Culture describe how the organization’s values, fairness, and tolerance of at-risk behaviors impact patient safety4 and describe components of an effective safety information system and learning environment.5 Safety must be a value, not a priority. Priorities can shift, whereas values are inherent in the organization. These readings make it clear that patient safety must be the primary value of the organization. Operational efficiency and financial targets cannot displace patient safety. Pharmacy leaders must use their actions to consistently demonstrate this. An organization that rewards employees who can handle high workloads can send mixed messages to staff, especially if dangerous workarounds are used in times of high volume. 3. Education about my medications. This includes the what, how, when, and why to take all of my medications. Education about medications is important for patient safety and outcomes. There is ample literature support for the role of the pharmacist as the provider of medication-related patient education.6-10 The pharmacist should be performing this education wherever possible. There may be situations where pharmacy departments in hospitals are not able to reach every patient. This right can serve as a goal for pharmacy departments to ensure that all patients receive the education they deserve. However, as with the previous 2 rights, this right specifies what needs to be done, not who should do it. If the pharmacy department is currently not able to reach every patient, it still has an
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obligation to ensure that the patients receive proper education. Whether this education is completed by another discipline, such as nursing or physicians, or by pharmacy students, the pharmacy department needs to make certain that the education happens and that it is of the highest quality possible. 4. Meet my pharmacist and understand what he/she does. As opposed to the previous 3 rights, which focused on what should happen rather than who should do it, the last 2 rights focus specifically on the pharmacist and the pharmacy staff. The fourth right stems from the fact that while pharmacists are often mentioned as the most accessible health care profession, pharmacists remain in many cases an unknown resource in hospitals from the patient perspective. The American Society of Health-System Pharmacists created the ‘‘Just Ask’’ campaign to address this issue. As they note, ‘‘Patients sometimes don’t even realize that there is a pharmacy department in the hospital or that pharmacists are key members of the patient’s healthcare team.’’11 Meeting the pharmacist and learning what he or she does will allow the patient to take better advantage of the pharmacist’s expertise. 5. A knowledgeable and skilled pharmacy workforce. There has been much talk in the profession recently about the need for residency training12 and board certification13 for pharmacists. The education and certification of pharmacy technicians has also been discussed.13 Due to the increased complexity of medication regimens and automation and increased pressure on pharmacy departments to do more with less due to changing reimbursement models, the need for a well-trained pharmacy staff has never been greater. Residency training, board certification, and technician training and education are all components of a welltrained staff. However, the burden still remains on the leadership of the pharmacy department to ensure that staff is adequately prepared to handle the duties asked of them. This pertains not only to clinical knowledge, but also to department and hospital-specific policies and procedures. QUALITY IMPROVEMENT FROM THE PATIENT PERSPECTIVE The pharmacy patient bill of rights establishes a framework for departments to use in making decisions
Guest Editorial
that are in the best interests of the patient. Up until this point, we have focused on issues that impact individual patients. However, pharmacy operations can have a broader impact. Pharmacy departments operate with various degrees of efficiency. In addition to the inherent patient safety implications, operational inefficiency leads to waste. Labor, medications, and supplies are all casualties of an inefficient system. All of these add up to substantial costs to the institution. Ultimately these costs are transferred to the patients. Wasteful systems are subsidized by increased patient care costs. Therefore, when viewed from the patient’s perspective, it is imperative that pharmacy departments try to improve efficiency. This does not mean that operational efficiency should be valued over patient safety. As previously discussed, patient safety must always be the primary value. This does mean that departments should work smarter, not harder, to minimize overproduction and waste. LEAN methodology is a concept from the manufacturing world that can help pharmacy departments to be just that. LEAN means ‘‘using less time, money, inventory, and space to increase value from the patient’s perspective.’’14 For more information and quality improvement tools, see American Society of HealthSystem Pharmacists’ Quality Improvement Resource Center (https://www.ashp.org/menu/PracticePolicy/ ResourceCenters/QII/Learn-About-QI.aspx#3). SUMMARY Pharmacy departments face competing pressures on a daily basis. New challenges arise constantly. Although financial constraints, drug shortages, and technologies are ever changing, one thing that does not change is the pharmacist’s role to serve the patient. The pharmacy patient bill of rights can be used to make sure that pharmacy departments keep the patient in mind when making all decisions. REFERENCES 1. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267-270. 2. Leach RH, Feetam C, Butler D. An evaluation of a ward pharmacy service. J Clin Hosp Pharm. 1981;6:173-182.
3. American Society of Health-System Pharmacists. ASHP Statement on the role of the medication safety leader. http:// www.ashp.org/DocLibrary/BestPractices/ MedMisStLeader.aspx. Accessed February 9, 2013. 4. Institute for Save Medication Practices. Just culture and its critical link to patient safety (Part I). ISMP Medication Safety Alert. Published May 17, 2012. http://www.ismp.org/ Newsletters/acutecare/showarticle.asp?id522. Accessed February 10, 2013. 5. Institute for Save Medication Practices. Just culture and its critical link to patient safety (Part II). ISMP Medication Safety Alert. Published July 12, 2012. http://www.ismp.org/newsletters/ acutecare/showarticle.asp?id526. Accessed February 10, 2013. 6. Garica-Caballos M, Ramos-Diaz F, Jimenez-Moleon JJ, Bueno-Cavanillas A. Drug-related problems in older people after hospital discharge and interventions to reduce them. Age Ageing. 2010;39(4):430-438. 7. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166: 565-571. 8. Hatoum HT, Hutchinson RA, Lambert BL. OBRA 90: patient counseling—enhancing patient outcomes. US Pharm. 1993;18(Jan):76-86. 9. OBRA ’90: A Practical Guide to Effecting Pharmaceutical Care. Washington, DC: American Pharmaceutical Association; 1994. 10. American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Health Syst Pharm. 1997;54:431-434. 11. American Society of Health-System Pharmacists. Just ask campaign. http://www.ashp.org/menu/PracticePolicy/ResourceCenters/ PublicRelations/ PracticeSite/JustAskCampaign.aspx. Accessed February 9, 2013. 12. 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: 722-733. 13. The consensus of the Pharmacy Practice Model Summit. Am J Health Syst Pharm. 2011; 68:1148–1152. 14. American Society of Health-System Pharmacists. Applying LEAN to the medication use process. https://www.ashp.org/ DocLibrary/Policy/QII/ApplyingLEAN_Flyer.pdf. Accessed February 10, 2013. g
Hospital Pharmacy
353
Copyright of Hospital Pharmacy is the property of Thomas Land Publishers Incorporated 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.
Guest Editorial Pharmacy Patient Bill of Rights: Practice Advancement From the Patient Perspective Jeff Little, PharmD, MPH, BCPS,p and Scott Mark, PharmD, MS, MEd, MPH, MBA, FASHP, FACHE, FABC†
I
t can be said that the role of the health care professional is to protect the public from that which they cannot protect themselves. While this concept is somewhat abstract, it is a useful exercise to further delineate the protections afforded by health care professionals. The risk points in the health care system and corresponding protections required by those risk points will vary by profession and by practice site. This exercise can then lead to a profession- and site-specific patient bill of rights. This bill of rights can be used to guide future decisions to ensure that all decisions are made with the best interests of the patients in mind. PHARMACY PATIENT BILL OF RIGHTS As with all licensed professions, practicing pharmacy is not a right, it is a privilege. This privilege is granted by the people of the state that issues the license. In return, the public asks for the type of protection described in the introduction. Keeping this concept in mind, pharmacies can develop a pharmacy patient bill of rights. The bill of rights is written from the point of view of the patient. This seemingly small point is actually crucial to bring home the point that everything that the health system pharmacist does needs to be viewed from the perspective of the patient. The items on the bill of rights may seem self-explanatory; however, each point is worthy of discussion. 1. I have a right to have only indicated medications ordered for and administered to me. Before exploring the downstream effects of this right, there needs to be some discussion of what is an indicated medication. Criteria used to determine whether a medication is indicated include the patient’s diagnosis, physical characteristics, past medical history, and level of care (acuity) and the medication’s relative cost-effectiveness. Given that understanding, the pharmacy department must then decide how to position itself
to make sure that this right is not violated. One thing that becomes clear is that the pharmacy must know as much about the patient as possible. Any opportunity to have a pharmacist participate in patient care rounds should be taken advantage of. Although the benefits of pharmacist participation in these rounds have been well established,1,2 many departments may view the benefits as intervention-based. That is, the pharmacist is there to intervene and make recommendations. It is true that pharmacists can improve patient care by making recommendations on rounds, but this does not mean that if a pharmacist does not make a recommendation on rounds, then there was no benefit to the patient. Going on rounds provides the pharmacist access to knowledge about the patient that may otherwise be hard to discover. Another thing that becomes clear when viewed from the perspective of the patient is that this information must be utilized. The pharmacist who knows the most about the patient is in the best position to ensure that the patient gets the indicated medications ordered and administered. Therefore, this right can help drive a pharmacy department to integrate the rounding pharmacist into the distributive process (eg, verifying orders if the hospital has a computerized prescriber order entry system). 2. I have the right to a safe medication process that incorporates the ‘‘5 Rights.’’ The ‘‘5 Rights’’ (the right patient, the right drug, the right dose, the right route, the right time) are familiar to hospital workers, because they deal with medication administration. When viewed from the perspective of the patient, it becomes clear that the pharmacy department can increase the ability of the person who administers the medication to satisfy the 5 Rights. Many pharmacy department decisions will have downstream effects on the ability to ensure everything is correct regarding the medication. Automation, packaging,
*Assistant Director of Pharmacy, Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; †Director, Huron Healthcare Consulting Group, Chicago, Illinois
Hospital Pharmacy
351
Guest Editorial
label code, clinical decision support, drug nomenclature, and so on can impact the likelihood that the person administering the medication is able to do so as accurately as possible. Therefore, the involvement of the people who administer medications in these decisions is a necessity. Additionally, the pharmacists who are physically closest to the patient are also physically closest to medication administration processes. Therefore, they are in the best position to help ensure that the 5 Rights are met. To do this, these pharmacists must have active knowledge of the pharmacy department’s distribution process. Separating the direct patient care and distributive functions of pharmacists interferes with their ability to promote the 5 Rights and therefore goes against this concept. This leads to discussion of the organization’s culture. Current recommendations are for institutions to operate within a Just Culture.3 Recent publications from the Institute for Safe Medication Practices regarding Just Culture describe how the organization’s values, fairness, and tolerance of at-risk behaviors impact patient safety4 and describe components of an effective safety information system and learning environment.5 Safety must be a value, not a priority. Priorities can shift, whereas values are inherent in the organization. These readings make it clear that patient safety must be the primary value of the organization. Operational efficiency and financial targets cannot displace patient safety. Pharmacy leaders must use their actions to consistently demonstrate this. An organization that rewards employees who can handle high workloads can send mixed messages to staff, especially if dangerous workarounds are used in times of high volume. 3. Education about my medications. This includes the what, how, when, and why to take all of my medications. Education about medications is important for patient safety and outcomes. There is ample literature support for the role of the pharmacist as the provider of medication-related patient education.6-10 The pharmacist should be performing this education wherever possible. There may be situations where pharmacy departments in hospitals are not able to reach every patient. This right can serve as a goal for pharmacy departments to ensure that all patients receive the education they deserve. However, as with the previous 2 rights, this right specifies what needs to be done, not who should do it. If the pharmacy department is currently not able to reach every patient, it still has an
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Volume 48, May 2013
obligation to ensure that the patients receive proper education. Whether this education is completed by another discipline, such as nursing or physicians, or by pharmacy students, the pharmacy department needs to make certain that the education happens and that it is of the highest quality possible. 4. Meet my pharmacist and understand what he/she does. As opposed to the previous 3 rights, which focused on what should happen rather than who should do it, the last 2 rights focus specifically on the pharmacist and the pharmacy staff. The fourth right stems from the fact that while pharmacists are often mentioned as the most accessible health care profession, pharmacists remain in many cases an unknown resource in hospitals from the patient perspective. The American Society of Health-System Pharmacists created the ‘‘Just Ask’’ campaign to address this issue. As they note, ‘‘Patients sometimes don’t even realize that there is a pharmacy department in the hospital or that pharmacists are key members of the patient’s healthcare team.’’11 Meeting the pharmacist and learning what he or she does will allow the patient to take better advantage of the pharmacist’s expertise. 5. A knowledgeable and skilled pharmacy workforce. There has been much talk in the profession recently about the need for residency training12 and board certification13 for pharmacists. The education and certification of pharmacy technicians has also been discussed.13 Due to the increased complexity of medication regimens and automation and increased pressure on pharmacy departments to do more with less due to changing reimbursement models, the need for a well-trained pharmacy staff has never been greater. Residency training, board certification, and technician training and education are all components of a welltrained staff. However, the burden still remains on the leadership of the pharmacy department to ensure that staff is adequately prepared to handle the duties asked of them. This pertains not only to clinical knowledge, but also to department and hospital-specific policies and procedures. QUALITY IMPROVEMENT FROM THE PATIENT PERSPECTIVE The pharmacy patient bill of rights establishes a framework for departments to use in making decisions
Guest Editorial
that are in the best interests of the patient. Up until this point, we have focused on issues that impact individual patients. However, pharmacy operations can have a broader impact. Pharmacy departments operate with various degrees of efficiency. In addition to the inherent patient safety implications, operational inefficiency leads to waste. Labor, medications, and supplies are all casualties of an inefficient system. All of these add up to substantial costs to the institution. Ultimately these costs are transferred to the patients. Wasteful systems are subsidized by increased patient care costs. Therefore, when viewed from the patient’s perspective, it is imperative that pharmacy departments try to improve efficiency. This does not mean that operational efficiency should be valued over patient safety. As previously discussed, patient safety must always be the primary value. This does mean that departments should work smarter, not harder, to minimize overproduction and waste. LEAN methodology is a concept from the manufacturing world that can help pharmacy departments to be just that. LEAN means ‘‘using less time, money, inventory, and space to increase value from the patient’s perspective.’’14 For more information and quality improvement tools, see American Society of HealthSystem Pharmacists’ Quality Improvement Resource Center (https://www.ashp.org/menu/PracticePolicy/ ResourceCenters/QII/Learn-About-QI.aspx#3). SUMMARY Pharmacy departments face competing pressures on a daily basis. New challenges arise constantly. Although financial constraints, drug shortages, and technologies are ever changing, one thing that does not change is the pharmacist’s role to serve the patient. The pharmacy patient bill of rights can be used to make sure that pharmacy departments keep the patient in mind when making all decisions. REFERENCES 1. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267-270. 2. Leach RH, Feetam C, Butler D. An evaluation of a ward pharmacy service. J Clin Hosp Pharm. 1981;6:173-182.
3. American Society of Health-System Pharmacists. ASHP Statement on the role of the medication safety leader. http:// www.ashp.org/DocLibrary/BestPractices/ MedMisStLeader.aspx. Accessed February 9, 2013. 4. Institute for Save Medication Practices. Just culture and its critical link to patient safety (Part I). ISMP Medication Safety Alert. Published May 17, 2012. http://www.ismp.org/ Newsletters/acutecare/showarticle.asp?id522. Accessed February 10, 2013. 5. Institute for Save Medication Practices. Just culture and its critical link to patient safety (Part II). ISMP Medication Safety Alert. Published July 12, 2012. http://www.ismp.org/newsletters/ acutecare/showarticle.asp?id526. Accessed February 10, 2013. 6. Garica-Caballos M, Ramos-Diaz F, Jimenez-Moleon JJ, Bueno-Cavanillas A. Drug-related problems in older people after hospital discharge and interventions to reduce them. Age Ageing. 2010;39(4):430-438. 7. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166: 565-571. 8. Hatoum HT, Hutchinson RA, Lambert BL. OBRA 90: patient counseling—enhancing patient outcomes. US Pharm. 1993;18(Jan):76-86. 9. OBRA ’90: A Practical Guide to Effecting Pharmaceutical Care. Washington, DC: American Pharmaceutical Association; 1994. 10. American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Health Syst Pharm. 1997;54:431-434. 11. American Society of Health-System Pharmacists. Just ask campaign. http://www.ashp.org/menu/PracticePolicy/ResourceCenters/ PublicRelations/ PracticeSite/JustAskCampaign.aspx. Accessed February 9, 2013. 12. 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: 722-733. 13. The consensus of the Pharmacy Practice Model Summit. Am J Health Syst Pharm. 2011; 68:1148–1152. 14. American Society of Health-System Pharmacists. Applying LEAN to the medication use process. https://www.ashp.org/ DocLibrary/Policy/QII/ApplyingLEAN_Flyer.pdf. Accessed February 10, 2013. g
Hospital Pharmacy
353
Copyright of Hospital Pharmacy is the property of Thomas Land Publishers Incorporated 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.
