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 … 2 x

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:

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

Emerging evidence but still a lot of unknowns about their impact 2008

Implementation of CPOEs 5% in % 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 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:

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 …