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The Pharmacy Practice Model Initiative As a Tool For Inpatient Care

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The Pharmacy Practice Model Initiative (PPMI) focuses the concentrated criterion within hospital pharmacies towards areas of practice that will result in the greatest beneficial outcome for inpatient care and overall hospital pharmacy efficiency. Although ASHP’s PPMI contains 147 recommendations for improvement in hospital pharmacies, Michigan’s PPMI conference summarizes these recommendations into a handful of focused categories, including “education and training, organizational affairs and leadership, pharmacy technicians, and technology and information systems.”1 At this conference, officials concluded that over 80% of the recommendations promised high impact and feasibility if implemented in hospital pharmacies.1 The optimistic conclusion of the Michigan conference yields promising evidence that other states may easily adopt the PPMI, which creates new opportunities for hospital pharmacy practice across the country. Of the various recommendations, educating pharmacy technicians, implementing new technologies, and health care team integration appear to be the most promising means of incorporating PPMI in institutional settings.

PPMI can improve hospital pharmacy by encouraging technicians to take on roles that are more involved in the workplace. According to Myers, “a disconnect exists between fulfilling the medication-use needs of health-system patients and the current qualifications of most pharmacy technicians,” which holds back the profession of pharmacy from addressing those patient needs.2 In order to bridge this disconnect, the Northwest Medical Center in Tucson, Arizona, increased the roles of its pharmacy technicians. This expands the practice of hospital pharmacy by allowing them to specialize in one particular area: medication reconciliation. The specific goal of this project was to improve patient outcomes by ensuring all patients received their critical medications while staying there. Lincoln writes that these technicians were specially trained on the critical medications list, and if they determined that any patient information was incomplete, they would contact another member of the healthcare team caring for that individual.3 There are multiple benefits to having pharmacy technicians more involved in patient care. By thoroughly training technicians, they can serve as an additional check during medication reconciliation, which is an excellent way to improve the use of hospital resources. Patient outcomes also benefit as well because the reconciliation is performed by both the technician and by the pharmacist. With this additional verification step, identifying and resolving potential medication errors is more likely. As the roles of pharmacy technicians are expanded, pharmacists can deviate from the traditional role of dispensing and focus on addressing the individual needs of patients in a more direct, personalized manner.

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Out of all of the recommendations set forth by ASHP, our group believes that leveraging pharmacy technicians is the initiative we would implement first. Currently, pharmacy technicians employed in Pennsylvania are not required to complete technician certification courses. For pharmacy technicians to practice in Pennsylvania, they must follow the state regulations enforced by the State Board of Pharmacy and a written protocol describing permissible duties.4 With the addition of more responsibilities, it is plausible to increase the educational requirements to practice as a technician in order to ensure the competency of technicians’ abilities to do their jobs safely, responsibly and efficiently. For example, it should be required for technicians to become Certified Pharmacy Technicians, which includes passing the Pharmacy Technician Certification Exam.5 By increasing the roles of technicians in hospital pharmacy, more tasks can be delegated to them, leaving the pharmacists on duty to focus on more clinical, personalized delivery of health care. Not only does this have benefits for quality of care, but it also is a veritable means of reducing health care costs as the resources already available to the staff can be allocated more economically.

Another main component of PPMI is the integration of available technologies in order to support patient safety and quality of care. Although verification of the patient’s medications can be obtained from the patient first-hand, technology can be incorporated to obtain patient history directly from the patient’s physician or from other hospital records. With this technology, the use of available automation also reduces costs by decreasing errors that are a result of miscommunication and data transfers.6 For example, Vanderbilt University Medical Center implemented an informatics program for pharmacy personnel in order to strive toward improving patient care by minimizing errors.7 They executed a procedure that specified the electrolytes needing replacement in pediatric patients and only allowed these specific electrolytes to be dispensed. This information was sent to the electronic medical record and computerized provider order entry systems which then determined the appropriate dosing based on patient information. With the implementation of this technology, all members of a patient’s health care team have access to the same real-time information, immensely reducing redundancy and other medical errors. As more technological advances are made in the institutional setting, the workflow in the pharmacy can become more streamlined while still maintaining excellent quality of care.

University of North Carolina Hospitals’ team-based approach to PPMI has also proven to be effective. This team-based model is known as a layered learning practice model or LLPM.8 The major component of this team model is the incorporation of pharmacy students and residents into clinical rounds who are overseen by an attending pharmacist. Kayla Hansen, the clinical manager, says that their “multi-faceted team approach [enables them] to meet demands of the current healthcare system as well as adjust to incorporate new priorities.”9 An example of a demand that the team approach allows the hospitals to work towards is patient-centered care. Hansen explains that putting the patients first describes the ideal pharmacy practice module, and their way of achieving this is through the team approach. In Hansen’s own words, “with the patient as the focus, the practice model develops with teamwork that incorporates all pharmacists, residents, students, technicians, and pharmacy staff for the common goal of achieving safe and effective medication use.”9 Another benefit of this model is allowing the pharmacist responsible for the patient throughout their entirety of hospital stay to consult with the rest of the team to make decisions. These two benefits alone make a positive impact on the patient’s outcomes. Not only do they proactively reduce mistakes through consulting with team members, but they also provide students and residents with hands-on training with working alongside other health care professionals. UNC hospital’s team model is so unique and innovative that they even received a grant to study it further in order to “develop a consistent approach that will lay the groundwork for broad-scale implementation of the model.”8 Nicole Pinelli, PharmD, is the principal investigator of the grant and explains the benefits: “The idea is that by having multiple people on the pharmacy team, we could offer comprehensive medication therapy management, improve care coordination, and provide additional services that would not be possible in the old model.”8 What the researchers and practitioners at the UNC hospitals have been working towards is a model that encourages the best patient outcomes through a team-based approach, while also incorporating adequate training of pharmacy students and residents.

As a group, we decided that in order to make PPMI an even more successful project in hospitals, we would like to implement more hospital-focused rotation blocks for students who are interested in pursuing this field of pharmacy. With hospital pharmacy rotations for students lasting no longer than a few weeks, the timeframe of hospital pharmacy experience and education creates a very prominent barrier to the maintenance of the PPMI in hospital pharmacy practice. Many hospital pharmacy members may take time to acclimate to the changes presented by PPMI, but these full-time staff members will have the rest of their careers to adapt to the PPMI criteria.10 However, pharmacy students on rotation receive little exposure to these changes, as they have limited time to understand the hospital pharmacy setting and fully integrate the PPMI into their method of practice before moving on to a new rotation. Therefore, the universities of students who show great interest in hospital pharmacy should offer additional consecutive block periods during the students’ sixth year rotations in order to increase the amount of experience within a hospital setting that a student may receive within a given period of time. These consecutive block rotations should ideally be placed towards end of the student’s graduating year, providing a more fluid transition for those who intend to work full-time in a hospital pharmacy. Students are then able to maintain a hospital mentality during their rotations, seamlessly transitioning into the hospital pharmacist role and continuing their PPMI education for the remainder of their pharmacy career.

By increasing the roles of technicians, making better use of technology, and focusing on a more team-based approach to care, hospital pharmacy can be transformed from the traditional aspect of dispensing to a more patient-centered method of care. If implemented, the recommendations set forth by ASHP in the PPMI have the opportunity to redefine the role of pharmacists in institutional settings across the United States. Hopefully, the PPMI will focus the practice of pharmacy on a blended model, allowing pharmacists to care for patients more resourcefully, seamlessly, and synergistically. This will ultimately lead to improved clinical, economic, and humanistic outcomes in the health care field. As the practice of pharmacy and the roles of pharmacists change, the health care needs of the community can be addressed more successfully, leading to happier and healthier patients and more fluid workflow in the hospital.

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