Adoption of Change in Hospital
Pharmacy Practice
Jean-François Bussières
B Pharm MSc MBA FCSHP
Chef, département de pharmacie et unité de recherche en pratique
pharmaceutique, CHU Sainte-Justine
Professeur titulaire de clinique, Faculté de pharmacie, Université de Montréal
Kevin Hall
B. Sc. Pharm., Pharm. D., FCSHP
Clinical Associate Professor
Faculty of Pharmacy and Pharmaceutical Sciences
University of Alberta
Objectives
• To understand the typical trajectory associated with
the adoption of change, following the initial
availability of evidence supporting the change
• To discuss possible ways of accelerating the
adoption of evidence-based improvements in the
practice of pharmacy
Adoption of change in healthcare
Following the availability of evidence supporting
the adoption of a new healthcare practice, how
many years do you think will pass, on average,
before the improved practice will be in widespread
usage?
•
•
•
•
•
2 years?
5 years?
9 years?
17 years?
25 years?
Balas et al.
Managing clinical knowledge for health
care improvement
• 1843
– Oliver Wendell Holmes
– Boston Society for Medical Improvement
– Contagiousness of puerperal fever
– Advocated hand washing before examining a
pregnant woman … « a revolutionary idea at
the time »
‘Managing clinical knowledge for health care
improvement’
• Studied nine clinical procedures
• Calculated the annual increase in use by dividing the current
rate of use by the number of years between the publication of
the landmark trial and the reported current use
• Average: 3.2% increase each year
• 15.6 years required before an innovation is used by 50% of
potential users
There was twice as much evidence
available in 1995 than there was in 1966
Imagine now …
2x
The nine clinical interventions
Calculated
that on
average
it takes
17 years
for research
evidence to
reach clinical
practices
Does the figure of 17 years seem
excessive for the adoption of change in
hospital pharmacy practice?
Sources of information used to identify
key issues in pharmacy practice
• Pharmacy and other Scientific Literature
• Hospital Pharmacy in Canada Report
• CSHP 2015 Survey Results
What information can we glean from
these sources concerning the adoption
of change in pharmacy practice?
Trends from the HPC Report
• Six examples ….
– Unit-dose distribution service
– IV admixture service
– Use of barcodes in the drug-use process
– Implementation of computerized prescriber
order entry (CPOE) systems
– Pharmacy technician scope of practice
– Pharmacist scope of practice
Adoption of change in Pharmacy
Practice
• Approximately when was the innovation proven
to be beneficial?
• What level of implementation had been achieved
by 2012?
Source: Parker P. Unit-dose systems reduce error, increase efficiency.
Hospitals JAHA
1968
; 42: 65-72.
Unit-dose distribution systems
65 %
2012
minus
1968
=
44 years and and the use of unit
dose systems, full or partial, was
reported by only 65% of respondents
!
1978
IV admixture to > 90% patients
64 % in 2012
2012
minus
1978
=
34 years !
1974
Use of barcoding in hospital pharmacy
Range of 2-22% in 2012
2012
minus
1974
=
38 years !
Computerized prescriber order entry
systems
2008
Emerging
evidence
but still
a lot of
unknowns
about their
impact
Implementation of CPOEs
5% in 2004
9% in 2012
Scope of Practice Changes for
Pharmacists and Pharmacy
Technicians
Pharmacy Technician Scope of
Practice
• “The counting and pouring often alleged to
be the pharmacist’s chief occupation will in
time be done by technicians and eventually
by automation. The pharmacist of tomorrow
will function by reason of what he knows,
increasing the efficiency and safety of drug
therapy and working as a specialist in his
own right.”, Dean Tice of the Philadelphia
College of Pharmacy 1961
2012
2012
minus
1961
=
51 years !
Pharmacist Scope of Practice
• “I would establish as the principal
qualifications of a clinical practitioner that he
bear personal responsibility for the safe and
effective use of drugs in a number of patients
on a continuing basis.”
• Don Francke 1976
Independent prescribing rights for
pharmacists
Alberta allowed pharmacists to acquire
independent prescribing rights beginning in 2006.
Since then, what percentage of pharmacists have
obtained independent prescribing rights?
4% ?
10% ?
18% ?
50% ?
71% ?
2012
minus
1976
=
36 years !
Pharmacy technicians as a support
role for clinical services
8
to
37%
(excluding
drug
distribution
liaison)
Is Pharmacy an evidence-based
Profession?
No evidence
for clinical
activities
=
higher priority
Source: http://www.lillyhospitalsurvey.ca/hpc2/content/home.asp
So why do changes occur
so slowly ?
• Why do we have such significant gaps between
objectives, priorities and implementation ?
– Limited resources ($, human)?
– Too many competing priorities?
– Lack of leadership?
– Staff attitudes?
• What contributes to the successes that are reported?
– Passion and motivation?
– Staff awareness?
– Incorportation of CSHP 2015 in strategic planning?
– Inspirational leadership?
Barriers to change …
•
•
•
•
Unsuccessful passive diffusion …
Results difficult to understand …
Too much information …
People feel they should not change what
works !
• No expertise …
• No incentive …
• Fear …