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Developing a practice site in the non-academic community hospital: A primer for pharmacy practice faculty members
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Currents in Pharmacy Teaching and Learning 7 (2015) 899–907
Opinion
http://www.pharmacyteaching.com
Developing a practice site in the non-academic community hospital: A primer for pharmacy practice faculty members Montgomery F. Williams, PharmD, BCPSa,*, Trent G. Towne, PharmD, BCPS (AQ-ID)b, Sarah E. Griffin, PharmDc b
a Department of Pharmacy Practice, College of Pharmacy, Belmont University, Nashville, TN Department of Pharmacy Practice, College of Pharmacy, Manchester University, Fort Wayne, IN c Department of Pharmacy Practice, College of Pharmacy, Harding University, Searcy, AR
Abstract The need for quality advanced pharmacy practice experiences (APPEs) and clinical practice sites for pharmacy faculty in inpatient settings continues to increase with the expansion of colleges of pharmacy. Since the patient care model in non-academic community hospitals often differs from the traditional model in an academic institution, the development of a practice site and experiential education in this setting requires a strategic approach by the faculty member. This article was developed by three full-time pharmacy practice faculty at different colleges of pharmacy who were each tasked with developing a new part-time practice site at a non-academic community hospital. Included are strategies for establishing the site, overcoming barriers to the creation of an optimal practice environment, and keeping the momentum once the site has been established. The various roles of a faculty member in this setting and some of the advantages to practicing within a non-academic community hospital are also presented. As the landscape of pharmacy education continues to evolve, successful development and perspectives from these practice sites should be shared. r 2015 Elsevier Inc. All rights reserved.
Keywords: Practice site development; Non-academic community hospital; Non-academic hospital
Introduction Many pharmacy practice faculty members may complete a significant portion of their formal training as students and residents in large academic medical centers. Following their post-graduate training, faculty members may practice at non-academic community hospitals yet have little or no experience in these types of facilities. The growth in the number of colleges of pharmacy and the increased need for experiential education sites (both introductory and advanced) has required some practice faculty members to develop practice sites outside of traditional academic medical centers * Corresponding author: Montgomery F. Williams, PharmD, BCPS, College of Pharmacy, Belmont University, 1900 Belmont Boulevard, Nashville, TN 37212 E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2015.08.016 1877-1297/r 2015 Elsevier Inc. All rights reserved.
in order to meet growing pharmacy education needs.1 Based on data from the American Hospital Association Hospital Statistics and Association of American Medical Colleges, 7% of all registered United States hospitals are members of the Council of Teaching Hospitals and Health Systems.2,3 Consequently, the vast majority of registered hospitals are non-academic community hospitals. Previously published articles address the importance and development of advanced clinical pharmacy services in the non-academic community hospital setting.4,5 While the size, scope, and services provided may vary significantly, non-academic community hospitals present a unique set of opportunities and challenges for a faculty member newly entering this practice environment. This article was developed by three full-time practice faculty members at different colleges of pharmacy who have compiled their shared experiences related to establishment of
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clinical practice sites at non-academic community hospitals (range in size: 185–450 beds). Although specific aspects of practice vary somewhat at each institution, the challenges and successes were similar. The purpose of this article is to provide perspectives to other full-time pharmacy faculty who are assigned to or charged with developing part-time clinical practice sites at non-academic community hospitals. This article aims to define the roles and responsibilities of the faculty member, describe how to establish the site, suggest ways to overcome barriers to creating an optimal practice environment, give examples of how to keep momentum after establishing the site, and highlight advantages of this type of practice setting.
Defining roles and responsibilities of a faculty member at a non-academic community hospital The overarching goal of developing a practice site is to optimize patient care and provide a structured environment for student learning during Advanced Pharmacy Practice Experiences (APPEs). There are four primary duties for a practice faculty member with a part-time role at a nonacademic community hospital including provision of clinical pharmacy services, service to the health system, creation of educational opportunities, and development of scholarly endeavors. Contemplating these duties and understanding the needs of stakeholders at the facility is a critical early step in the development of patient care activities at a new practice site. Institutional stakeholders may include students, physicians, patients, fellow pharmacists, residents, pharmacy administration, and hospital administration. Additionally, the college of pharmacy where the full-time faculty member is employed should be considered a major stakeholder. All of the varied expectations should be defined prior to or during the early phase of assuming the position at a practice site. It is necessary to ensure that the goals and expectations of the practice faculty, including patient care and educational opportunities, are aligned with those of all stakeholders prior to assuming the role at the practice site. Ideally, the faculty member should also be involved in the goal-setting sessions to ensure that all parties develop achievable goals. Overarching goals should include: (1) establishing clinical pharmacy services that ensure optimal medication therapy for the patient population served, (2) identifying opportunities for service to the health system that are mutually beneficial to the institution, faculty member, and college of pharmacy, (3) creating educational opportunities for students that meet the objectives set by the college and the Accreditation Council for Pharmacy Education (ACPE), and (4) identifying and cultivating areas for scholarly activity.
Table 1 includes suggestions for specific approaches to meet these goals. Establishing a practice site Providing clinical services with the intention to precept pharmacy students starts with establishing a practice site. Although the practice faculty member may not be involved in the selection of the practice site, identifying an appropriate practice site is paramount for success. The site should meet the needs of the curriculum and align with faculty interest and expertise.6 A potential site should have patient care needs for which the faculty can utilize their skills, as well as the ability to accommodate experiential students.6 Availability of physical space for both the students and faculty, opportunities for developing a patient care practice, and access to inter-professional collaboration should be considered when identifying a site in a non-academic community hospital. Early interactions with administration at the site can ensure that the college’s and the hospital’s goals are achievable. A great way to help solidify these goals is through the formation of a contract. A contract between the college and the practice site should address issues of expectations, funding, and roles and responsibilities. Just as the contract or business agreement with the site defines the faculty member’s scope of practice, understanding the funding of this position helps to determine prioritization of workload at both the college and the clinical practice site. All parties should agree on the percentage of time spent at both the college and the practice site, though it may not always be possible to precisely determine depending on teaching requirements at the college. A schedule should be provided and accepted by both the college and the practice site with the understanding that certain events such as graduation and other major college and/or hospital meetings may alter the precise balance of this time. While a contract or business agreement cements the relationship among the college, faculty member, and practice site, creating a job description is an excellent way to ensure that roles and expectations at the site are clear. The job description (Table 1) should be concise, yet it should consider all aspects of practice, scholarship, service, and citizenship. When possible, it should provide specific examples of plans for patient care activities and collaboration opportunities with other members of the health care team. Participation in hospital committees or other service activities also may be agreed upon by all involved parties and defined within the job description. While it is important that the job description is comprehensive and precise, appropriate latitude should be afforded so that as the practice site develops, opportunities are not missed. Upon completion of the job description, both the practice site and college approval should be sought. Copies of this document should be kept on file by the practice site, the college department chair, and the faculty member. Patient care activities are largely dictated by the scope of clinical services that currently exist at the site and the
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Table 1 Example job description Purpose: serve both the hospital and college by providing services, which include collaborating with other health care providers, serving as an educational resource, establishing a clinical pharmacy practice site, and engaging in scholarly activity. Responsibilities: Collaborate with other members of the health care team
Establish professional relationships with physicians, nurses, fellow pharmacists, and other health care providers in order to optimize patient care As time allows, attend pharmacy-related and departmental meetings
Serve as an educational resource
Provide drug information to patients and caregivers Provide educational in-services to other members of the health care team as requested and as time permits Precept APPE student pharmacists Establish an APPE in general medicine in accordance with ACPE and the requirements of the college of pharmacy Create a syllabus and calendar for monthly rotational expectations Provide opportunities for students to achieve rotation goals and objectives while expanding students’ clinical skills and cultivating independence Facilitate students’ interaction with other members of the health care team by establishing opportunities for students to shadow physicians, nurses, and other health care professionals as time allows Assign and supervise projects and presentations which will enhance the students’ rotational experience
Establish a clinical pharmacy practice site
Establish a clinical pharmacy practice site that meets the goals, expectations, and needs of the hospital, physicians, and college of pharmacy Function as a member of the pharmacy department and serve as a liaison between the hospital and college of pharmacy Provide clinical services including Completing independent evaluations of patients’ medication regimens Making appropriate therapeutic recommendations to the health care team Participating in medication reconciliation activities Monitoring drug therapy for effectiveness and adverse reactions Collaborating with the health care team to optimize medication regimens Documenting all necessary interventions in accordance with hospital policy Establishing a protocol to identify priority therapeutic interventions Be an efficient user of pharmacy information technology as required to perform pharmacist responsibilities
Engage in scholarly activity
Identify and cultivate areas for scholarly activity including: Implementation of quality improvement and cost savings projects Documentation of medication events
APPE ¼ advanced pharmacy practice experience; ACPE ¼ Accreditation Council for Pharmacy Education.
faculty member’s area of expertise. Initial opportunities for pharmacist-provided direct patient care will vary and are based on the current practice model at the hospital and availability of structured pharmacist interaction with providers.5 Depending on the practice setting, these activities can take place as either part of a multidisciplinary rounding team, one-on-one physician rounds, or prospective patient chart review. Some non-academic community hospitals may have interdisciplinary patient care rounds that the faculty member can join to provide patient care. If this opportunity does exist, the full-time faculty member will need to ensure that his/her schedule allows for consistent attendance during rounds. Another opportunity may include attending daily or weekly interdisciplinary meetings (“huddles”) in order to
stay abreast of patient progress and make therapeutic recommendations. If no such interdisciplinary opportunity exists, clinical services can be provided through prospective patient chart review and making recommendations to providers to optimize patient care. The patient population that the faculty member will serve can be determined by several methods, including the location or unit of patients, specific provider availability for collaboration, disease state (s)/medications of focus, or high-risk patient populations. One author experienced successful integration by reviewing charts of at-risk patients who were identified using a computerized alert system to prioritize the need for review. Alerts identified which patients had infectious markers (high fever or white count) with no treatment, those who needed
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Table 2 Protocol for prioritization of patients Purpose: to establish a protocol to prioritize pharmacist review for general medicine patients seen by the hospitalist physician group. Patients seen by the hospitalist physician group will be prioritized for pharmacist review using the following criteria: Patients presenting to the hospital taking more than ten (10) medications as an outpatient (polypharmacy) This should include reviewing the patient’s home medication regimen and ensuring the appropriateness of all outpatient medications. Patients initiated on an antibiotic regimen while in the hospital. This should include reviewing the selected antibiotic regimen for appropriateness regarding the selection of an empiric antibiotic regimen, culture results, response to therapy, and any adverse drug reactions. Patients who are receiving any anticoagulant. This should include monitoring for appropriateness of dosages with aPTT for heparin, INR for warfarin, as well as renal function for enoxaparin, dabigatran, bivalirudin, and factor Xa inhibitors. This should also include monitoring for drug interactions, any adverse events, appropriate duration of therapy, and effectiveness. Patients on any medication that should be monitored by drug therapeutic levels. This should include phenytoin, vancomycin, aminoglycosides, valproic acid, digoxin, and any other medication agreed upon between the physician and pharmacist. Patients with renal dysfunction that may require adjustment of medication dosages. Patients who require medication education (as designated by hospital policy) before being discharged. The pharmacist shall proactively review all hospitalist group patients’ medication regimens as time permits and make necessary recommendations to the health care team. The pharmacist shall allow for time to respond to any drug information requests from any member of the health care team, patient, or patient’s caregiver. INR ¼ international normalized ratio; aPTT ¼ activated partial thromboplastin time.
de-escalation of empiric antibiotics, and out-of-range drug levels. This prompted at least 3–4 interventions per day. Another author developed a protocol for prioritization of patients to aid in stratifying patients for review (Table 2). Understanding the culture and history of the hospital and pharmacy department is important in facilitating integration and aids in accomplishing the second duty of providing service to the health system. Gaining this perspective will help the faculty member avoid any missteps during the initial time at the site and identify opportunities for improvement that may benefit the system. Integration into the pharmacy department is crucial and every effort should be made for the faculty member to serve as an extension of the pharmacy department. This is especially true in community hospitals where the pharmacy and medical staff may have worked closely together for many years. An important way to achieve this goal is to be trained at the hospital similar to a newly hired staff or clinical pharmacist. Appropriate training in protocols, policies, and procedures aids in becoming an integral part of the pharmacy department and equips the faculty member to serve as a pharmacy resource throughout the facility. Additionally, the relationships developed during training foster a sense of teamwork and provide a great model for experiential students. Professional relationships developed during the first months at a new practice site create the foundation for success as a clinician and educator at the institution. Identifying the specialties and areas of interest among fellow pharmacists can be very helpful in determining how the faculty member’s strengths and interests can be integrated into the current practice model. Having this type of understanding may also open doors and permit expansion of services that benefits both the practice site and the college.
Involvement in hospital committees and initiatives provides a valuable service to the hospital and a route for faculty members to have an impact on a larger patient population. Participation in these committees offers the faculty member the ability to extend or even expand services within the institution by utilizing established connections and demonstrating professional expertise. Valuable relationships with other health care providers can develop on committees, in particular when the faculty member serves as a drug information and educational resource. These connections provide better integration into the practice site and ultimately enhances the students’ educational experience. Regular attendance at pharmacy meetings can help the faculty member become a part of the pharmacy team and stay current with departmental issues. Involvement with hospital committees provides an excellent way to network within the institution while promoting the pharmacy department and its relationship with the college of pharmacy. The opportunities for committee work at a non-academic community hospital can be a bit more variable and may require a faculty member to step outside of his/her specified area of expertise in order to be a contributing member. Opportunities for committee service may include Pharmacy and Therapeutics, Antimicrobial Stewardship, Medication Safety, or other committees in the faculty member’s specialty area. One author provided meaningful cost versus usage information for a particular drug to physicians during a committee meeting, which influenced prescribing habits and decreased patient adverse events. The service and committee component at the practice site also can potentially contribute to the college’s promotion and tenure process.
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Table 3 Timeline for initial development of a practice site Elements
Description
Time to Completion
Draft and final contract for practice site
Ensure that expectations of the college and site are consistent Provide mechanism for credentialing at practice site
Prior to the faculty member hire date or soon thereafter
Create a job description
Should reflect the roles and responsibilities of the faculty member Within the first month at the site at the practice site May identify direct supervisor and evaluation structure
Training regarding pharmacy operations and departmental culture
Undergo training consistent with a newly hired member of the pharmacy department (operations, policies, procedures, etc.) Attendance at pharmacy department meetings Fostering internal relationships with pharmacy colleagues
Build a clinical identity at the practice site
Direct involvement in patient care activities Within the first six months at Regular participation and engagement in health system committees the site
Develop APPE rotation experience
Within the first six months at Determine the number of students your site can support and the the site best times to precept during the academic year Determine how students will be involved in patient care activities Identify additional educational experiences for students Counseling patients Medication reconciliation (admission and/or discharge) Project development/data collection
Within the first three months at the site
APPE ¼ advanced pharmacy practice experience.
Establishing educational opportunities that create an optimal environment for student learning on APPEs is the third duty of a faculty member. This takes time since establishing collaborative relationships with other health care providers and setting up the clinical practice site are necessary to ensure an optimal learning environment. An ideal environment allows students to provide patient care while enhancing their therapeutic knowledge and experiencing inter-professional collaboration.6 An example of successful integration is evident in one author’s institution, where health care providers seek out students to assist in patient care or patient counseling. Optimally, a full-time faculty member is provided a minimum of six months to complete the steps to establish a new practice site in order to appropriately integrate APPE students.6 Table 3 provides a timeline for the initial development of a practice site, including a description of how to complete each step and a proposed timeframe. An initial step when structuring and planning for experiential students is to be clear on how many students (both introductory and advanced) the faculty member is expected to precept and to make sure that both the site and college agree on this number. With the appropriate number of students and strategic planning, the formation of this academic environment at the hospital can enhance integration into the practice site. Barriers and ways to overcome them Developing and maintaining a practice site at a nonacademic community hospital presents several challenges.
Balancing time between the hospital and college is one. While responsibilities of full-time faculty at the college may vary significantly depending on the time of year, maintaining a consistent part-time schedule at the hospital helps establish the expectations of those with whom the faculty member works. Ensuring that all necessary pharmacy personnel and providers know the faculty member’s availability helps minimize any misconceptions related to service at the site. Keeping an updated calendar that is easily accessible either through e-mail systems or adding scheduled time at the hospital to the pharmacy department schedule promotes transparency of availability. Considering all components of a given day, such as meetings and travel time between the site and college, may help a faculty member to manage commitments. If possible, the faculty member should make every effort to keep class schedule and teaching requirements consistent from semester to semester, as this will help alleviate some of the difficulty of having to adapt the practice site schedule to changes in teaching requirements. One author found it helpful to establish a set number of hours per week to be on-site at the hospital. The faculty member must ensure that any commitment made to the practice site aligns with established goals and is achievable with all other responsibilities. While many providers at non-academic community hospitals likely trained at academic medical centers, they may not have a clear understanding of the clinical pharmacist’s role and scope of practice in a non-academic community hospital. Another challenge facing a newly placed pharmacist may involve historical stereotypes and
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comparisons. Being available to providers, offering assistance, and following through with requests can help expose providers to the benefits of clinical pharmacists and ameliorate some of these stereotypes. Serving as a content area expert, assisting in solving challenging clinical care questions, and staying up-to-date with current medical literature will enhance communication and professional rapport and may lead to scholarship and service opportunities. This also helps inform others outside of the pharmacy department about the scope of practice for clinical pharmacists. In many cases, the demonstration of solid clinical skills and knowledge can lead to the development of more personal relationships that serve to further trust and engender a team environment. If inter-professional rounding does not exist, partnering with practitioners who are willing to collaborate can help demonstrate the benefits of the team approach and create champions who will facilitate further expansion of the collaborative model. Collaboration should begin with an explanation of the benefits of a clinical pharmacist’s service to patient care and opportunities to increase efficiency. Administrative buy-in is often a necessary first step to develop successful long-term collaborations. Coordinating the time and place for collaborative meetings should consider all involved parties and the impact on patient care flow (medication administration times, patient discharge times, etc.). Finally, the faculty member can serve as a catalyst to ensure that these meetings are efficient and meet everyone’s expectations and needs. Regardless of the type of service, the quickest way for the faculty member to overcome barriers is to demonstrate capabilities as a competent and compassionate provider. For students completing experiential education at the practice site, requirements of both the college and ACPE provide the framework for the types of opportunities a wellrounded APPE experience should offer. Organized and thorough orientation with explicit directions and expectations will help facilitate the process of student involvement and ensure a smooth transition for the students into the practice site. Group orientation and activities (such as presentations and topic discussions) can be coordinated if there are other pharmacists who serve as preceptors at the site. The faculty member must provide students with structured and meaningful patient care activities. If available, students can participate in multidisciplinary meetings or structured patient care rounds; however, if these opportunities are not available, students may participate in prospective patient chart reviews. It is important that the faculty member provide students guidance through the prospective patient chart review process. Creating patient data collection forms with specific information for the students to gather can help facilitate this process. Patient selection for student review can be based on a specific patient care area or provider, complexity of the patients’ disease states and medication regimens, or specific disease states of interest. The students can then be given time to review and present their assigned patients to allow for
knowledge assessment and the ability to independently identify interventions. Students should also be given opportunities to directly communicate with patients and other health care providers. One author developed a process for APPE student to complete admission medication histories in the emergency department during rotation hours to increase patient interaction while also providing a much needed service to the hospital. In situations where direct interaction with health care providers is not structured, students should be given the opportunity to approach providers with recommendations and coached on communication of these recommendations. One author found it helpful to have APPE students make more basic interventions such as intravenous to oral conversions and renal dose adjustments at the beginning of the rotation and increase the complexity of student recommendations towards the end of the rotation (such as de-escalation of antibiotic therapy and adjusting therapy to meet guideline recommendations). Supplementing daily patient care responsibilities with other aspects of the faculty member’s role within the hospital such as meeting The Joint Commission goals, documentation of interventions, and development of policy and practice guidelines is also educational. Students can also spend a day shadowing willing providers. One author had success pairing APPE students with students from other disciplines, as a physician assistant student stated that he learned more when a pharmacy student rounded with the physician than at other times. The goal is to develop a practice site such that APPE students augment the services the faculty member provides. Having students review charts independently after appropriate training and oversight can help streamline time management for the full-time faculty member and allow time to work on other projects. Some examples of areas for student involvement include medication reconciliation, patient counseling, core measure performance, and data collection for medication use projects. Communication of pharmacotherapy recommendations and patient care interventions can be challenging if the faculty member is not involved in daily rounds or if providers are not readily available for questions.5 Effectively communicating important interventions and pertinent discussion with other health care professionals to colleagues in the pharmacy department is necessary for optimal therapeutic outcomes and continuity of care. Developing a systematic approach to communicate these recommendations can facilitate a consistent message and source of information for providers. This communication can occur either via paper/electronic communication or in person with the provider at an established meeting time. Discussion of recommendations in person more effectively builds professional relationships with providers than written alternatives do. Since the identification of pertinent recommendations is often unpredictable and may not coincide with providers’ schedules, it is necessary for the faculty member and students to be adequately prepared and organized in order to make recommendations in a timely manner. A few ways to achieve this goal is to make sure that students arrive early
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enough to thoroughly review selected patients, ensure that students prioritize at-risk patients via training from the faculty member, and provide practice with brief and accurate recommendations. Communicating recommendations using the SBAR (situation, background, assessment, and recommendation) method can also help to ensure that recommendations are complete and concise.7 Regardless of the avenue of communication, it is important that students learn to be efficient with their allotted time when communicating with providers. Flexibility also helps ensure that all needs are met and optimal patient care is delivered. To provide continuity of care any outstanding interventions or information not communicated with providers should be followed up by a designated colleague. This method of communication should be consistent and ideally provided to the person who will be responsible for completing the task. Daily pharmacist-to-pharmacist communication can be done verbally, via the electronic medical record, or via computerized documentation in a shared database. One author developed a communication spreadsheet that was saved to a shared drive and updated daily with any pertinent interventions, outstanding laboratory values, and pending recommendations. The faculty member’s effectiveness as a liaison hinges upon accurate and timely communication to all involved parties. Keeping momentum Successful development of a practice site in a nonacademic community hospital requires a significant investment of time and talents from the full-time faculty member. As important as early steps are in practice site development, it is equally important to provide consistency and sustainability of services to help keep momentum over time. These elements further demonstrate the value of the faculty member at the site to both the department chair at the college and the pharmacy manager. One way the full-time faculty member can accomplish this is by encouraging other pharmacists to expand their roles and at specified times share certain responsibilities of an established clinical service. Communication and camaraderie with fellow pharmacists encourages others to step into the clinical role and assist in providing these services and educational experiences. One author aided the institution in the implementation of a warfarin order set. Equipped with recent experience in an anticoagulation clinic, the faculty member assisted fellow pharmacist colleagues in this transition of services by serving as a consultant for recommendations. This service helped the pharmacists feel more confident in their clinical recommendations. Another author has been involved in the development of an antimicrobial stewardship service and conducted several educational sessions for the pharmacy department regarding evaluating culture results and appropriate selection of antimicrobials to increase fellow pharmacists comfort level when making antimicrobial stewardship recommendations. This author
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remains available to pharmacy colleagues by telephone when not on site to provide any additional assistance with recommendations regarding appropriate antimicrobial therapy. Momentum is also maintained by engaging in quality improvement initiatives from both a personal and institutional perspective. Assessing these outcomes may help the faculty member decide where to funnel efforts while continuing to develop and maintain the practice site. Continual assessment encourages life-long learning and increases job satisfaction. Documentation of involvement in committee work, policy/procedure development, and clinical interventions/ recommendations is crucial to continued success as a faculty member at a non-academic community hospital. The benefit of assessing documented activities is determining effectiveness of the clinical service provided. This information can identify areas for future initiatives and goals as well as potential areas for new faculty positions at the practice site. Meeting with the pharmacy director on a regular basis (monthly or quarterly) can help assess effectiveness and achievement of goals, and identify areas for improvement. Annual re-assessment of achievement of goals and establishing new goals ensures that the faculty member is meeting expectations and that the collaboration is fruitful for all involved. Preparing an annual report summarizing productivity at the site is an excellent way to demonstrate to the college and practice site the value the faculty member brings to both institutions. Furthermore, this report, which might include intervention data, projects completed, pertinent committee involvement, and any feedback (either in a written letter or evaluation form) provided by the pharmacy director at the practice site, can be extremely useful and should be included in the faculty member’s annual performance evaluations and promotion and tenure dossiers. Maintaining a quality APPE is in part dependent upon the ability to match the educational needs of the experiential students with the needs of the site. Frequent feedback from students and the site will help determine the quality of the APPE and if adjustments should be made to enhance the experience of all involved parties. Maintaining the momentum requires dedication to the tripartite mission of academia: teaching, service, and scholarship. The integration of scholarship into the everyday responsibilities of a practice site is the fourth duty of the faculty member and can provide a robust source for research projects. It is imperative to determine areas for potential research and scholarship activities not only for promotion and tenure requirements (if applicable) but also to maintain continued engagement and professional growth. Nonacademic community hospitals offer a variety of opportunities for scholarly activities. This environment may require the faculty member to be creative in identifying areas for scholarly activity. Quality improvement projects, cost savings projects, development of new services, tracking interventions to optimize patient care, and documentation of medication
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adverse events are possible areas for scholarly work. One author was involved in developing an educational initiative and quality improvement project to decrease inappropriate treatment of asymptomatic bacteriuria. The author was able to involve APPE students in developing the research proposal, Institutional Review Board submission, and data collection process. Integrating the collection of data for a study into daily practice habits or publishing a case report of a unique case can provide a great start to this process that benefits both the faculty member’s career and the hospital. Developing professional relationships at the site and keeping lines of communication open will help identify these opportunities and lay a path for success. As the need for pharmacy residency training programs expands, the full-time faculty member at a non-academic community hospital may be asked to assist in the development of or to participate in post-graduate year-1 or postgraduate year-2 (PGY1 or PGY2) residency programs.8 The faculty member may be involved in precepting residents or serving as a residency program director if he or she meets the qualifications of a director as set forth by the American Society of Health-System Pharmacists (ASHP).9 Qualifications necessary for this position include many activities in which the faculty member may already be involved in, such as institutional committee appointments, demonstration of effective teaching, documentation of improvements in pharmacy practice, and publication in professional journals.9 The faculty member also has the advantage of previously established support networks among nurses, physicians, and pharmacy that will aid in documenting the need for a residency program and securing funding. It is essential for the institution to have an appropriate number of pharmacy preceptors who are able to provide adequate training in ambulatory care, critical care, general medicine, and infectious disease required by ASHP in order for the program to be successful.9 Important questions to ask at the beginning are the following: “Should the program be accredited? How many resident positions should there be initially? Should the program be college affiliated?”10 One author’s facility uses faculty preceptors from a newly founded college of pharmacy for resident training. The development of the PGY1 program was delayed by four years to ensure preceptors had well established sites for proper training of residents. This program is now accredited and has certified four residents. Residency programs can have a positive impact by providing extra staffing for certain shifts and other longitudinal services such as adverse drug event reporting and drug information services. Pharmacy residents can provide sustainability of daily projects that may not be easily maintained by a full-time faculty member due to off-site responsibilities. Other beneficial aspects of being involved with a residency program can include supervising residency research projects and serving on a residency advisory committee. Additionally, students, residents, and other pharmacists may be interested in a research idea and can share in the data collection and article
or poster preparation. Residency preceptor development often includes training in the Residency Learning System (RLS) and using the preceptor’s role of direct instruction, modeling, coaching, and facilitating.11 This additional preceptor training can also be beneficial for the faculty member by further cultivating pedagogy skills that are useful when precepting APPE students. Faculty member involvement in a residency training program will not only benefit the site through the growth of clinical pharmacy services but also encourage the faculty member’s continued professional growth through expanding service and teaching in this realm. Advantages of a practice site at a non-academic community hospital Clinical pharmacy services may be underdeveloped in non-academic community hospitals and practicing in this setting offers several advantages. Opportunities to establish new services can enhance overall patient care. The authors have been involved in the successful development of interprofessional patient care by establishing a rounding service in a practice site and a multidisciplinary patient care meeting in another. The rounding service was established as a collaborative model between the faculty member and a pharmacist at the site who share duties on the service. The multidisciplinary patient care meeting allows for daily collaboration with case managers, dietitians, nurses, and physicians regarding patient status. Developing trust and accountability by being an available and reliable drug information resource on the floor has led to collaboration with other health care disciplines. The authors are now frequently sought out regarding appropriate selection and duration of antibiotics, appropriate dosing of medications, and optimization of medication regimens. Regardless of the structure of patient care activities, consistent documentation of interventions and accepted recommendations is a concrete method to demonstrate the faculty member’s (and APPE students) value to the site. Commercially available Clinical Decision Support software can help track the number and type of interventions made and assign a monetary value to interventions. One of the authors was able to document over 1300 interventions made in two years. As the faculty member is able to demonstrate value to the hospital, the expansion of clinical services may follow, opening doors for additional faculty members and positions funded by the hospital. In addition, practicing in a non-academic community hospital may give the faculty member the ability to recognize strengths and hone skills as an educator and a pharmacist. Examples of successful involvement have included service on Pharmacy and Therapeutics committee and development and presentation of several medication use evaluations that led to improved medication use and patient safety. Other specific patient safety projects have included the development of an insulin U-500 protocol and educational materials
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and a nurse-driven hypoglycemia management and documentation protocol. Two of the authors have been involved with the development of Antimicrobial Stewardship Programs and processes for measuring the outcomes associated with these programs. Whether the faculty member’s strengths lie in patient communication, policy and protocol development, information technology, or drug information, he/she can proactively identify opportunities to utilize strengths in a non-academic community hospital. The faculty member can educate patients on their new medications or help implement new computer technology by catching errors or recognizing inefficiencies in the system. Pharmacy or clinical managers might even seek the opinion of the faculty member in the non-academic community hospital when they are developing new medication policies or examining the appropriate use of new medications. The opportunities available in the development of clinical services are mirrored by the wide variety of clinical research that can be performed in this setting. Often overlooked are the nuances of routine daily practice that can be quickly and efficiently formulated into a research question for dissemination as a poster or article such as adverse drug events or development of a new policy, protocol, or educational initiative. Newly developed services that model a unique or different method of education for students, such as collaboration with home health nurses in transitions of care, are excellent places to expand the responsibilities of pharmacists and initiate research in a community setting. The authors have successfully published patient case reports and presented data at national meetings related to outcomes of quality improvement projects. The non-academic community hospital setting also gives many opportunities for experiential education students to expand their knowledge and awareness of different hospital systems. This setting can allow students to gain a greater understanding of how clinical and distributive pharmacy services are aligned within a non-academic institution and experience different administrative aspects of hospital pharmacy, and offers a perspective of institutional practice that promotes creative thinking for new ways to integrate the practice of pharmacy outside a traditional academic medical center. Conclusion Developing a part-time practice site at a non-academic community hospital can be a challenging and rewarding
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experience for a full-time faculty member. Being organized and aware of what to expect can help alleviate some of these challenges and provide many opportunities. Overall, this is an area where faculty members can make a large impact on patient care and be fulfilled as both educators and clinical pharmacists.
Conflicts of interest The authors have no conflicts of interest to disclose.
References 1. Brackett PD, Byrd DC, Duke LJ, et al. Barriers to expanding advanced pharmacy practice experience site availability in an experiential education consortium. Am J Pharm Educ. 2009;73 (5): Article 82. 2. American Hospital Association. Fast Facts on US Hospitals. 〈http://www.aha.org/research/rc/stat-studies/fast-facts.shtml〉; Accessed August 2, 2015. 3. American Association of Medical Colleges. Council of Teaching Hospitals and Health Systems. 〈https://www.aamc.org/ members/coth/〉; Accessed August 2, 2015. 4. Cobaugh DJ, Amin A, Bookwalter T, et al. ASHP–SHM joint statement on hospitalist–pharmacist collaboration. Am J Health Syst Pharm. 2008;65(3):260–263. 5. Waite LH, Heuser L, Winkler SR. Advanced clinical pharmacy services in a nonacademic community hospital. Am J Health Syst Pharm. 2014;71(12):989–993. 6. McGivney MS. Building an advanced pharmacy practice experience (APPE) site for doctor of pharmacy students. Curr Pharm Teach Learn. 2009;1(1):25–32. 7. Thomas CM, Bertram E, Johnson D. The SBAR communication technique. Nurse Educ. 2009;34(4):176–180. 8. Fuller PD, Smith KM, Hinman RK, et al. Value of pharmacy residency training: a survey of the academic medical center perspective. Am J Health Syst Pharm. 2012;69(2):158–165. 9. American Society of Health-system Pharmacists. ASHP Accreditation Standard for Postgraduate Year One (PGY1) Pharmacy Residency Programs. 〈http://www.ashp.org/DocLibrary/Accredita tion/ASD-PGY1-Standard.aspx〉; 2012 Accessed August 2, 2015. 10. Nelson BA. How to start a residency program. 〈http://www.ashp. org/DocLibrary/Accreditation/Starting-Residency/RTP-HowStar tResidencyPrgm.aspx〉; 2015 Accessed August 2, 2015. 11. Weitzel KW, Walters EA, Taylor J. Teaching clinical problem solving: a preceptor’s guide. Am J Health Syst Pharm. 2012;69(18): 1588–1599.
Currents in Pharmacy Teaching and Learning 7 (2015) 899–907
Opinion
http://www.pharmacyteaching.com
Developing a practice site in the non-academic community hospital: A primer for pharmacy practice faculty members Montgomery F. Williams, PharmD, BCPSa,*, Trent G. Towne, PharmD, BCPS (AQ-ID)b, Sarah E. Griffin, PharmDc b
a Department of Pharmacy Practice, College of Pharmacy, Belmont University, Nashville, TN Department of Pharmacy Practice, College of Pharmacy, Manchester University, Fort Wayne, IN c Department of Pharmacy Practice, College of Pharmacy, Harding University, Searcy, AR
Abstract The need for quality advanced pharmacy practice experiences (APPEs) and clinical practice sites for pharmacy faculty in inpatient settings continues to increase with the expansion of colleges of pharmacy. Since the patient care model in non-academic community hospitals often differs from the traditional model in an academic institution, the development of a practice site and experiential education in this setting requires a strategic approach by the faculty member. This article was developed by three full-time pharmacy practice faculty at different colleges of pharmacy who were each tasked with developing a new part-time practice site at a non-academic community hospital. Included are strategies for establishing the site, overcoming barriers to the creation of an optimal practice environment, and keeping the momentum once the site has been established. The various roles of a faculty member in this setting and some of the advantages to practicing within a non-academic community hospital are also presented. As the landscape of pharmacy education continues to evolve, successful development and perspectives from these practice sites should be shared. r 2015 Elsevier Inc. All rights reserved.
Keywords: Practice site development; Non-academic community hospital; Non-academic hospital
Introduction Many pharmacy practice faculty members may complete a significant portion of their formal training as students and residents in large academic medical centers. Following their post-graduate training, faculty members may practice at non-academic community hospitals yet have little or no experience in these types of facilities. The growth in the number of colleges of pharmacy and the increased need for experiential education sites (both introductory and advanced) has required some practice faculty members to develop practice sites outside of traditional academic medical centers * Corresponding author: Montgomery F. Williams, PharmD, BCPS, College of Pharmacy, Belmont University, 1900 Belmont Boulevard, Nashville, TN 37212 E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2015.08.016 1877-1297/r 2015 Elsevier Inc. All rights reserved.
in order to meet growing pharmacy education needs.1 Based on data from the American Hospital Association Hospital Statistics and Association of American Medical Colleges, 7% of all registered United States hospitals are members of the Council of Teaching Hospitals and Health Systems.2,3 Consequently, the vast majority of registered hospitals are non-academic community hospitals. Previously published articles address the importance and development of advanced clinical pharmacy services in the non-academic community hospital setting.4,5 While the size, scope, and services provided may vary significantly, non-academic community hospitals present a unique set of opportunities and challenges for a faculty member newly entering this practice environment. This article was developed by three full-time practice faculty members at different colleges of pharmacy who have compiled their shared experiences related to establishment of
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clinical practice sites at non-academic community hospitals (range in size: 185–450 beds). Although specific aspects of practice vary somewhat at each institution, the challenges and successes were similar. The purpose of this article is to provide perspectives to other full-time pharmacy faculty who are assigned to or charged with developing part-time clinical practice sites at non-academic community hospitals. This article aims to define the roles and responsibilities of the faculty member, describe how to establish the site, suggest ways to overcome barriers to creating an optimal practice environment, give examples of how to keep momentum after establishing the site, and highlight advantages of this type of practice setting.
Defining roles and responsibilities of a faculty member at a non-academic community hospital The overarching goal of developing a practice site is to optimize patient care and provide a structured environment for student learning during Advanced Pharmacy Practice Experiences (APPEs). There are four primary duties for a practice faculty member with a part-time role at a nonacademic community hospital including provision of clinical pharmacy services, service to the health system, creation of educational opportunities, and development of scholarly endeavors. Contemplating these duties and understanding the needs of stakeholders at the facility is a critical early step in the development of patient care activities at a new practice site. Institutional stakeholders may include students, physicians, patients, fellow pharmacists, residents, pharmacy administration, and hospital administration. Additionally, the college of pharmacy where the full-time faculty member is employed should be considered a major stakeholder. All of the varied expectations should be defined prior to or during the early phase of assuming the position at a practice site. It is necessary to ensure that the goals and expectations of the practice faculty, including patient care and educational opportunities, are aligned with those of all stakeholders prior to assuming the role at the practice site. Ideally, the faculty member should also be involved in the goal-setting sessions to ensure that all parties develop achievable goals. Overarching goals should include: (1) establishing clinical pharmacy services that ensure optimal medication therapy for the patient population served, (2) identifying opportunities for service to the health system that are mutually beneficial to the institution, faculty member, and college of pharmacy, (3) creating educational opportunities for students that meet the objectives set by the college and the Accreditation Council for Pharmacy Education (ACPE), and (4) identifying and cultivating areas for scholarly activity.
Table 1 includes suggestions for specific approaches to meet these goals. Establishing a practice site Providing clinical services with the intention to precept pharmacy students starts with establishing a practice site. Although the practice faculty member may not be involved in the selection of the practice site, identifying an appropriate practice site is paramount for success. The site should meet the needs of the curriculum and align with faculty interest and expertise.6 A potential site should have patient care needs for which the faculty can utilize their skills, as well as the ability to accommodate experiential students.6 Availability of physical space for both the students and faculty, opportunities for developing a patient care practice, and access to inter-professional collaboration should be considered when identifying a site in a non-academic community hospital. Early interactions with administration at the site can ensure that the college’s and the hospital’s goals are achievable. A great way to help solidify these goals is through the formation of a contract. A contract between the college and the practice site should address issues of expectations, funding, and roles and responsibilities. Just as the contract or business agreement with the site defines the faculty member’s scope of practice, understanding the funding of this position helps to determine prioritization of workload at both the college and the clinical practice site. All parties should agree on the percentage of time spent at both the college and the practice site, though it may not always be possible to precisely determine depending on teaching requirements at the college. A schedule should be provided and accepted by both the college and the practice site with the understanding that certain events such as graduation and other major college and/or hospital meetings may alter the precise balance of this time. While a contract or business agreement cements the relationship among the college, faculty member, and practice site, creating a job description is an excellent way to ensure that roles and expectations at the site are clear. The job description (Table 1) should be concise, yet it should consider all aspects of practice, scholarship, service, and citizenship. When possible, it should provide specific examples of plans for patient care activities and collaboration opportunities with other members of the health care team. Participation in hospital committees or other service activities also may be agreed upon by all involved parties and defined within the job description. While it is important that the job description is comprehensive and precise, appropriate latitude should be afforded so that as the practice site develops, opportunities are not missed. Upon completion of the job description, both the practice site and college approval should be sought. Copies of this document should be kept on file by the practice site, the college department chair, and the faculty member. Patient care activities are largely dictated by the scope of clinical services that currently exist at the site and the
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Table 1 Example job description Purpose: serve both the hospital and college by providing services, which include collaborating with other health care providers, serving as an educational resource, establishing a clinical pharmacy practice site, and engaging in scholarly activity. Responsibilities: Collaborate with other members of the health care team
Establish professional relationships with physicians, nurses, fellow pharmacists, and other health care providers in order to optimize patient care As time allows, attend pharmacy-related and departmental meetings
Serve as an educational resource
Provide drug information to patients and caregivers Provide educational in-services to other members of the health care team as requested and as time permits Precept APPE student pharmacists Establish an APPE in general medicine in accordance with ACPE and the requirements of the college of pharmacy Create a syllabus and calendar for monthly rotational expectations Provide opportunities for students to achieve rotation goals and objectives while expanding students’ clinical skills and cultivating independence Facilitate students’ interaction with other members of the health care team by establishing opportunities for students to shadow physicians, nurses, and other health care professionals as time allows Assign and supervise projects and presentations which will enhance the students’ rotational experience
Establish a clinical pharmacy practice site
Establish a clinical pharmacy practice site that meets the goals, expectations, and needs of the hospital, physicians, and college of pharmacy Function as a member of the pharmacy department and serve as a liaison between the hospital and college of pharmacy Provide clinical services including Completing independent evaluations of patients’ medication regimens Making appropriate therapeutic recommendations to the health care team Participating in medication reconciliation activities Monitoring drug therapy for effectiveness and adverse reactions Collaborating with the health care team to optimize medication regimens Documenting all necessary interventions in accordance with hospital policy Establishing a protocol to identify priority therapeutic interventions Be an efficient user of pharmacy information technology as required to perform pharmacist responsibilities
Engage in scholarly activity
Identify and cultivate areas for scholarly activity including: Implementation of quality improvement and cost savings projects Documentation of medication events
APPE ¼ advanced pharmacy practice experience; ACPE ¼ Accreditation Council for Pharmacy Education.
faculty member’s area of expertise. Initial opportunities for pharmacist-provided direct patient care will vary and are based on the current practice model at the hospital and availability of structured pharmacist interaction with providers.5 Depending on the practice setting, these activities can take place as either part of a multidisciplinary rounding team, one-on-one physician rounds, or prospective patient chart review. Some non-academic community hospitals may have interdisciplinary patient care rounds that the faculty member can join to provide patient care. If this opportunity does exist, the full-time faculty member will need to ensure that his/her schedule allows for consistent attendance during rounds. Another opportunity may include attending daily or weekly interdisciplinary meetings (“huddles”) in order to
stay abreast of patient progress and make therapeutic recommendations. If no such interdisciplinary opportunity exists, clinical services can be provided through prospective patient chart review and making recommendations to providers to optimize patient care. The patient population that the faculty member will serve can be determined by several methods, including the location or unit of patients, specific provider availability for collaboration, disease state (s)/medications of focus, or high-risk patient populations. One author experienced successful integration by reviewing charts of at-risk patients who were identified using a computerized alert system to prioritize the need for review. Alerts identified which patients had infectious markers (high fever or white count) with no treatment, those who needed
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Table 2 Protocol for prioritization of patients Purpose: to establish a protocol to prioritize pharmacist review for general medicine patients seen by the hospitalist physician group. Patients seen by the hospitalist physician group will be prioritized for pharmacist review using the following criteria: Patients presenting to the hospital taking more than ten (10) medications as an outpatient (polypharmacy) This should include reviewing the patient’s home medication regimen and ensuring the appropriateness of all outpatient medications. Patients initiated on an antibiotic regimen while in the hospital. This should include reviewing the selected antibiotic regimen for appropriateness regarding the selection of an empiric antibiotic regimen, culture results, response to therapy, and any adverse drug reactions. Patients who are receiving any anticoagulant. This should include monitoring for appropriateness of dosages with aPTT for heparin, INR for warfarin, as well as renal function for enoxaparin, dabigatran, bivalirudin, and factor Xa inhibitors. This should also include monitoring for drug interactions, any adverse events, appropriate duration of therapy, and effectiveness. Patients on any medication that should be monitored by drug therapeutic levels. This should include phenytoin, vancomycin, aminoglycosides, valproic acid, digoxin, and any other medication agreed upon between the physician and pharmacist. Patients with renal dysfunction that may require adjustment of medication dosages. Patients who require medication education (as designated by hospital policy) before being discharged. The pharmacist shall proactively review all hospitalist group patients’ medication regimens as time permits and make necessary recommendations to the health care team. The pharmacist shall allow for time to respond to any drug information requests from any member of the health care team, patient, or patient’s caregiver. INR ¼ international normalized ratio; aPTT ¼ activated partial thromboplastin time.
de-escalation of empiric antibiotics, and out-of-range drug levels. This prompted at least 3–4 interventions per day. Another author developed a protocol for prioritization of patients to aid in stratifying patients for review (Table 2). Understanding the culture and history of the hospital and pharmacy department is important in facilitating integration and aids in accomplishing the second duty of providing service to the health system. Gaining this perspective will help the faculty member avoid any missteps during the initial time at the site and identify opportunities for improvement that may benefit the system. Integration into the pharmacy department is crucial and every effort should be made for the faculty member to serve as an extension of the pharmacy department. This is especially true in community hospitals where the pharmacy and medical staff may have worked closely together for many years. An important way to achieve this goal is to be trained at the hospital similar to a newly hired staff or clinical pharmacist. Appropriate training in protocols, policies, and procedures aids in becoming an integral part of the pharmacy department and equips the faculty member to serve as a pharmacy resource throughout the facility. Additionally, the relationships developed during training foster a sense of teamwork and provide a great model for experiential students. Professional relationships developed during the first months at a new practice site create the foundation for success as a clinician and educator at the institution. Identifying the specialties and areas of interest among fellow pharmacists can be very helpful in determining how the faculty member’s strengths and interests can be integrated into the current practice model. Having this type of understanding may also open doors and permit expansion of services that benefits both the practice site and the college.
Involvement in hospital committees and initiatives provides a valuable service to the hospital and a route for faculty members to have an impact on a larger patient population. Participation in these committees offers the faculty member the ability to extend or even expand services within the institution by utilizing established connections and demonstrating professional expertise. Valuable relationships with other health care providers can develop on committees, in particular when the faculty member serves as a drug information and educational resource. These connections provide better integration into the practice site and ultimately enhances the students’ educational experience. Regular attendance at pharmacy meetings can help the faculty member become a part of the pharmacy team and stay current with departmental issues. Involvement with hospital committees provides an excellent way to network within the institution while promoting the pharmacy department and its relationship with the college of pharmacy. The opportunities for committee work at a non-academic community hospital can be a bit more variable and may require a faculty member to step outside of his/her specified area of expertise in order to be a contributing member. Opportunities for committee service may include Pharmacy and Therapeutics, Antimicrobial Stewardship, Medication Safety, or other committees in the faculty member’s specialty area. One author provided meaningful cost versus usage information for a particular drug to physicians during a committee meeting, which influenced prescribing habits and decreased patient adverse events. The service and committee component at the practice site also can potentially contribute to the college’s promotion and tenure process.
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Table 3 Timeline for initial development of a practice site Elements
Description
Time to Completion
Draft and final contract for practice site
Ensure that expectations of the college and site are consistent Provide mechanism for credentialing at practice site
Prior to the faculty member hire date or soon thereafter
Create a job description
Should reflect the roles and responsibilities of the faculty member Within the first month at the site at the practice site May identify direct supervisor and evaluation structure
Training regarding pharmacy operations and departmental culture
Undergo training consistent with a newly hired member of the pharmacy department (operations, policies, procedures, etc.) Attendance at pharmacy department meetings Fostering internal relationships with pharmacy colleagues
Build a clinical identity at the practice site
Direct involvement in patient care activities Within the first six months at Regular participation and engagement in health system committees the site
Develop APPE rotation experience
Within the first six months at Determine the number of students your site can support and the the site best times to precept during the academic year Determine how students will be involved in patient care activities Identify additional educational experiences for students Counseling patients Medication reconciliation (admission and/or discharge) Project development/data collection
Within the first three months at the site
APPE ¼ advanced pharmacy practice experience.
Establishing educational opportunities that create an optimal environment for student learning on APPEs is the third duty of a faculty member. This takes time since establishing collaborative relationships with other health care providers and setting up the clinical practice site are necessary to ensure an optimal learning environment. An ideal environment allows students to provide patient care while enhancing their therapeutic knowledge and experiencing inter-professional collaboration.6 An example of successful integration is evident in one author’s institution, where health care providers seek out students to assist in patient care or patient counseling. Optimally, a full-time faculty member is provided a minimum of six months to complete the steps to establish a new practice site in order to appropriately integrate APPE students.6 Table 3 provides a timeline for the initial development of a practice site, including a description of how to complete each step and a proposed timeframe. An initial step when structuring and planning for experiential students is to be clear on how many students (both introductory and advanced) the faculty member is expected to precept and to make sure that both the site and college agree on this number. With the appropriate number of students and strategic planning, the formation of this academic environment at the hospital can enhance integration into the practice site. Barriers and ways to overcome them Developing and maintaining a practice site at a nonacademic community hospital presents several challenges.
Balancing time between the hospital and college is one. While responsibilities of full-time faculty at the college may vary significantly depending on the time of year, maintaining a consistent part-time schedule at the hospital helps establish the expectations of those with whom the faculty member works. Ensuring that all necessary pharmacy personnel and providers know the faculty member’s availability helps minimize any misconceptions related to service at the site. Keeping an updated calendar that is easily accessible either through e-mail systems or adding scheduled time at the hospital to the pharmacy department schedule promotes transparency of availability. Considering all components of a given day, such as meetings and travel time between the site and college, may help a faculty member to manage commitments. If possible, the faculty member should make every effort to keep class schedule and teaching requirements consistent from semester to semester, as this will help alleviate some of the difficulty of having to adapt the practice site schedule to changes in teaching requirements. One author found it helpful to establish a set number of hours per week to be on-site at the hospital. The faculty member must ensure that any commitment made to the practice site aligns with established goals and is achievable with all other responsibilities. While many providers at non-academic community hospitals likely trained at academic medical centers, they may not have a clear understanding of the clinical pharmacist’s role and scope of practice in a non-academic community hospital. Another challenge facing a newly placed pharmacist may involve historical stereotypes and
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comparisons. Being available to providers, offering assistance, and following through with requests can help expose providers to the benefits of clinical pharmacists and ameliorate some of these stereotypes. Serving as a content area expert, assisting in solving challenging clinical care questions, and staying up-to-date with current medical literature will enhance communication and professional rapport and may lead to scholarship and service opportunities. This also helps inform others outside of the pharmacy department about the scope of practice for clinical pharmacists. In many cases, the demonstration of solid clinical skills and knowledge can lead to the development of more personal relationships that serve to further trust and engender a team environment. If inter-professional rounding does not exist, partnering with practitioners who are willing to collaborate can help demonstrate the benefits of the team approach and create champions who will facilitate further expansion of the collaborative model. Collaboration should begin with an explanation of the benefits of a clinical pharmacist’s service to patient care and opportunities to increase efficiency. Administrative buy-in is often a necessary first step to develop successful long-term collaborations. Coordinating the time and place for collaborative meetings should consider all involved parties and the impact on patient care flow (medication administration times, patient discharge times, etc.). Finally, the faculty member can serve as a catalyst to ensure that these meetings are efficient and meet everyone’s expectations and needs. Regardless of the type of service, the quickest way for the faculty member to overcome barriers is to demonstrate capabilities as a competent and compassionate provider. For students completing experiential education at the practice site, requirements of both the college and ACPE provide the framework for the types of opportunities a wellrounded APPE experience should offer. Organized and thorough orientation with explicit directions and expectations will help facilitate the process of student involvement and ensure a smooth transition for the students into the practice site. Group orientation and activities (such as presentations and topic discussions) can be coordinated if there are other pharmacists who serve as preceptors at the site. The faculty member must provide students with structured and meaningful patient care activities. If available, students can participate in multidisciplinary meetings or structured patient care rounds; however, if these opportunities are not available, students may participate in prospective patient chart reviews. It is important that the faculty member provide students guidance through the prospective patient chart review process. Creating patient data collection forms with specific information for the students to gather can help facilitate this process. Patient selection for student review can be based on a specific patient care area or provider, complexity of the patients’ disease states and medication regimens, or specific disease states of interest. The students can then be given time to review and present their assigned patients to allow for
knowledge assessment and the ability to independently identify interventions. Students should also be given opportunities to directly communicate with patients and other health care providers. One author developed a process for APPE student to complete admission medication histories in the emergency department during rotation hours to increase patient interaction while also providing a much needed service to the hospital. In situations where direct interaction with health care providers is not structured, students should be given the opportunity to approach providers with recommendations and coached on communication of these recommendations. One author found it helpful to have APPE students make more basic interventions such as intravenous to oral conversions and renal dose adjustments at the beginning of the rotation and increase the complexity of student recommendations towards the end of the rotation (such as de-escalation of antibiotic therapy and adjusting therapy to meet guideline recommendations). Supplementing daily patient care responsibilities with other aspects of the faculty member’s role within the hospital such as meeting The Joint Commission goals, documentation of interventions, and development of policy and practice guidelines is also educational. Students can also spend a day shadowing willing providers. One author had success pairing APPE students with students from other disciplines, as a physician assistant student stated that he learned more when a pharmacy student rounded with the physician than at other times. The goal is to develop a practice site such that APPE students augment the services the faculty member provides. Having students review charts independently after appropriate training and oversight can help streamline time management for the full-time faculty member and allow time to work on other projects. Some examples of areas for student involvement include medication reconciliation, patient counseling, core measure performance, and data collection for medication use projects. Communication of pharmacotherapy recommendations and patient care interventions can be challenging if the faculty member is not involved in daily rounds or if providers are not readily available for questions.5 Effectively communicating important interventions and pertinent discussion with other health care professionals to colleagues in the pharmacy department is necessary for optimal therapeutic outcomes and continuity of care. Developing a systematic approach to communicate these recommendations can facilitate a consistent message and source of information for providers. This communication can occur either via paper/electronic communication or in person with the provider at an established meeting time. Discussion of recommendations in person more effectively builds professional relationships with providers than written alternatives do. Since the identification of pertinent recommendations is often unpredictable and may not coincide with providers’ schedules, it is necessary for the faculty member and students to be adequately prepared and organized in order to make recommendations in a timely manner. A few ways to achieve this goal is to make sure that students arrive early
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enough to thoroughly review selected patients, ensure that students prioritize at-risk patients via training from the faculty member, and provide practice with brief and accurate recommendations. Communicating recommendations using the SBAR (situation, background, assessment, and recommendation) method can also help to ensure that recommendations are complete and concise.7 Regardless of the avenue of communication, it is important that students learn to be efficient with their allotted time when communicating with providers. Flexibility also helps ensure that all needs are met and optimal patient care is delivered. To provide continuity of care any outstanding interventions or information not communicated with providers should be followed up by a designated colleague. This method of communication should be consistent and ideally provided to the person who will be responsible for completing the task. Daily pharmacist-to-pharmacist communication can be done verbally, via the electronic medical record, or via computerized documentation in a shared database. One author developed a communication spreadsheet that was saved to a shared drive and updated daily with any pertinent interventions, outstanding laboratory values, and pending recommendations. The faculty member’s effectiveness as a liaison hinges upon accurate and timely communication to all involved parties. Keeping momentum Successful development of a practice site in a nonacademic community hospital requires a significant investment of time and talents from the full-time faculty member. As important as early steps are in practice site development, it is equally important to provide consistency and sustainability of services to help keep momentum over time. These elements further demonstrate the value of the faculty member at the site to both the department chair at the college and the pharmacy manager. One way the full-time faculty member can accomplish this is by encouraging other pharmacists to expand their roles and at specified times share certain responsibilities of an established clinical service. Communication and camaraderie with fellow pharmacists encourages others to step into the clinical role and assist in providing these services and educational experiences. One author aided the institution in the implementation of a warfarin order set. Equipped with recent experience in an anticoagulation clinic, the faculty member assisted fellow pharmacist colleagues in this transition of services by serving as a consultant for recommendations. This service helped the pharmacists feel more confident in their clinical recommendations. Another author has been involved in the development of an antimicrobial stewardship service and conducted several educational sessions for the pharmacy department regarding evaluating culture results and appropriate selection of antimicrobials to increase fellow pharmacists comfort level when making antimicrobial stewardship recommendations. This author
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remains available to pharmacy colleagues by telephone when not on site to provide any additional assistance with recommendations regarding appropriate antimicrobial therapy. Momentum is also maintained by engaging in quality improvement initiatives from both a personal and institutional perspective. Assessing these outcomes may help the faculty member decide where to funnel efforts while continuing to develop and maintain the practice site. Continual assessment encourages life-long learning and increases job satisfaction. Documentation of involvement in committee work, policy/procedure development, and clinical interventions/ recommendations is crucial to continued success as a faculty member at a non-academic community hospital. The benefit of assessing documented activities is determining effectiveness of the clinical service provided. This information can identify areas for future initiatives and goals as well as potential areas for new faculty positions at the practice site. Meeting with the pharmacy director on a regular basis (monthly or quarterly) can help assess effectiveness and achievement of goals, and identify areas for improvement. Annual re-assessment of achievement of goals and establishing new goals ensures that the faculty member is meeting expectations and that the collaboration is fruitful for all involved. Preparing an annual report summarizing productivity at the site is an excellent way to demonstrate to the college and practice site the value the faculty member brings to both institutions. Furthermore, this report, which might include intervention data, projects completed, pertinent committee involvement, and any feedback (either in a written letter or evaluation form) provided by the pharmacy director at the practice site, can be extremely useful and should be included in the faculty member’s annual performance evaluations and promotion and tenure dossiers. Maintaining a quality APPE is in part dependent upon the ability to match the educational needs of the experiential students with the needs of the site. Frequent feedback from students and the site will help determine the quality of the APPE and if adjustments should be made to enhance the experience of all involved parties. Maintaining the momentum requires dedication to the tripartite mission of academia: teaching, service, and scholarship. The integration of scholarship into the everyday responsibilities of a practice site is the fourth duty of the faculty member and can provide a robust source for research projects. It is imperative to determine areas for potential research and scholarship activities not only for promotion and tenure requirements (if applicable) but also to maintain continued engagement and professional growth. Nonacademic community hospitals offer a variety of opportunities for scholarly activities. This environment may require the faculty member to be creative in identifying areas for scholarly activity. Quality improvement projects, cost savings projects, development of new services, tracking interventions to optimize patient care, and documentation of medication
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adverse events are possible areas for scholarly work. One author was involved in developing an educational initiative and quality improvement project to decrease inappropriate treatment of asymptomatic bacteriuria. The author was able to involve APPE students in developing the research proposal, Institutional Review Board submission, and data collection process. Integrating the collection of data for a study into daily practice habits or publishing a case report of a unique case can provide a great start to this process that benefits both the faculty member’s career and the hospital. Developing professional relationships at the site and keeping lines of communication open will help identify these opportunities and lay a path for success. As the need for pharmacy residency training programs expands, the full-time faculty member at a non-academic community hospital may be asked to assist in the development of or to participate in post-graduate year-1 or postgraduate year-2 (PGY1 or PGY2) residency programs.8 The faculty member may be involved in precepting residents or serving as a residency program director if he or she meets the qualifications of a director as set forth by the American Society of Health-System Pharmacists (ASHP).9 Qualifications necessary for this position include many activities in which the faculty member may already be involved in, such as institutional committee appointments, demonstration of effective teaching, documentation of improvements in pharmacy practice, and publication in professional journals.9 The faculty member also has the advantage of previously established support networks among nurses, physicians, and pharmacy that will aid in documenting the need for a residency program and securing funding. It is essential for the institution to have an appropriate number of pharmacy preceptors who are able to provide adequate training in ambulatory care, critical care, general medicine, and infectious disease required by ASHP in order for the program to be successful.9 Important questions to ask at the beginning are the following: “Should the program be accredited? How many resident positions should there be initially? Should the program be college affiliated?”10 One author’s facility uses faculty preceptors from a newly founded college of pharmacy for resident training. The development of the PGY1 program was delayed by four years to ensure preceptors had well established sites for proper training of residents. This program is now accredited and has certified four residents. Residency programs can have a positive impact by providing extra staffing for certain shifts and other longitudinal services such as adverse drug event reporting and drug information services. Pharmacy residents can provide sustainability of daily projects that may not be easily maintained by a full-time faculty member due to off-site responsibilities. Other beneficial aspects of being involved with a residency program can include supervising residency research projects and serving on a residency advisory committee. Additionally, students, residents, and other pharmacists may be interested in a research idea and can share in the data collection and article
or poster preparation. Residency preceptor development often includes training in the Residency Learning System (RLS) and using the preceptor’s role of direct instruction, modeling, coaching, and facilitating.11 This additional preceptor training can also be beneficial for the faculty member by further cultivating pedagogy skills that are useful when precepting APPE students. Faculty member involvement in a residency training program will not only benefit the site through the growth of clinical pharmacy services but also encourage the faculty member’s continued professional growth through expanding service and teaching in this realm. Advantages of a practice site at a non-academic community hospital Clinical pharmacy services may be underdeveloped in non-academic community hospitals and practicing in this setting offers several advantages. Opportunities to establish new services can enhance overall patient care. The authors have been involved in the successful development of interprofessional patient care by establishing a rounding service in a practice site and a multidisciplinary patient care meeting in another. The rounding service was established as a collaborative model between the faculty member and a pharmacist at the site who share duties on the service. The multidisciplinary patient care meeting allows for daily collaboration with case managers, dietitians, nurses, and physicians regarding patient status. Developing trust and accountability by being an available and reliable drug information resource on the floor has led to collaboration with other health care disciplines. The authors are now frequently sought out regarding appropriate selection and duration of antibiotics, appropriate dosing of medications, and optimization of medication regimens. Regardless of the structure of patient care activities, consistent documentation of interventions and accepted recommendations is a concrete method to demonstrate the faculty member’s (and APPE students) value to the site. Commercially available Clinical Decision Support software can help track the number and type of interventions made and assign a monetary value to interventions. One of the authors was able to document over 1300 interventions made in two years. As the faculty member is able to demonstrate value to the hospital, the expansion of clinical services may follow, opening doors for additional faculty members and positions funded by the hospital. In addition, practicing in a non-academic community hospital may give the faculty member the ability to recognize strengths and hone skills as an educator and a pharmacist. Examples of successful involvement have included service on Pharmacy and Therapeutics committee and development and presentation of several medication use evaluations that led to improved medication use and patient safety. Other specific patient safety projects have included the development of an insulin U-500 protocol and educational materials
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and a nurse-driven hypoglycemia management and documentation protocol. Two of the authors have been involved with the development of Antimicrobial Stewardship Programs and processes for measuring the outcomes associated with these programs. Whether the faculty member’s strengths lie in patient communication, policy and protocol development, information technology, or drug information, he/she can proactively identify opportunities to utilize strengths in a non-academic community hospital. The faculty member can educate patients on their new medications or help implement new computer technology by catching errors or recognizing inefficiencies in the system. Pharmacy or clinical managers might even seek the opinion of the faculty member in the non-academic community hospital when they are developing new medication policies or examining the appropriate use of new medications. The opportunities available in the development of clinical services are mirrored by the wide variety of clinical research that can be performed in this setting. Often overlooked are the nuances of routine daily practice that can be quickly and efficiently formulated into a research question for dissemination as a poster or article such as adverse drug events or development of a new policy, protocol, or educational initiative. Newly developed services that model a unique or different method of education for students, such as collaboration with home health nurses in transitions of care, are excellent places to expand the responsibilities of pharmacists and initiate research in a community setting. The authors have successfully published patient case reports and presented data at national meetings related to outcomes of quality improvement projects. The non-academic community hospital setting also gives many opportunities for experiential education students to expand their knowledge and awareness of different hospital systems. This setting can allow students to gain a greater understanding of how clinical and distributive pharmacy services are aligned within a non-academic institution and experience different administrative aspects of hospital pharmacy, and offers a perspective of institutional practice that promotes creative thinking for new ways to integrate the practice of pharmacy outside a traditional academic medical center. Conclusion Developing a part-time practice site at a non-academic community hospital can be a challenging and rewarding
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experience for a full-time faculty member. Being organized and aware of what to expect can help alleviate some of these challenges and provide many opportunities. Overall, this is an area where faculty members can make a large impact on patient care and be fulfilled as both educators and clinical pharmacists.
Conflicts of interest The authors have no conflicts of interest to disclose.
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