- Email: [email protected]
Pharmacy Executive Leadership Issues and Associated Skills Knowledge and Abilities
RESEARCH
Pharmacy Executive Leadership Issues and Associated Skills, Knowledge, and Abilities Andrew B. Meadows, Lucinda L. Maine, Elizabeth K. Keyes, Kathy Pearson, and Kenn Finstuen
Received November 7, 2003, and in revised form March 29, 2004. Accepted for publication May 4, 2004.
ABSTRACT Objectives: To identify challenges that current and future pharmacy executives are facing or will face in the future and to define what skills, knowledge, and abilities (SKAs) are required to successfully negotiate these challenges. Design: Delphi method for executive decision making. Setting: Civilian pharmacy profession. Participants: 110 pharmacists who graduated from the GlaxoSmithKline Executive Management Program for Pharmacy Leaders. Interventions: Two iterations of the Delphi method for executive decision making separated by an expert panel content analysis. Main Outcome Measures: Round 1—participants were asked to identify five major issues they believed to be of greatest importance to pharmacy leaders in the next 5–10 years and name specific SKAs that might be needed by future leaders to successfully deal with those issues. An expert panel reviewed the issues, classified issues into specific domains, and titled each domain. Round 2—participants rated the SKAs on a 7-point scale according to their individual assessment of importance in each domain. Results: For Delphi rounds 1 and 2, response rates were 21.8% and 18.2%, respectively. More than 100 total issue statements were identified. The expert panel sorted the issues into five domains: management and development of the pharmacy workforce, pharmacy finance, total quality management of workflow systems, influences on the practice of pharmacy, and professional pharmacy leadership. Five of the top 15 SKAs—and all four highest ranked items— came from the professional pharmacy leadership domain, including ability to see the big picture, ability to demonstrate the value of pharmacy services, ability to lead and manage in an ethical manner, and skills for influencing an organization’s senior leadership. Conclusion: Through successful integration of communication skills, critical thinking, and problem solving techniques, future public-sector pharmacy executives will be better equipped to effectively position their organizations and the profession for the challenges that lie ahead. Keywords: Delphi method, future, leadership, competency, professional development, pharmacists. J Am Pharm Assoc. 2005;45:55–62.
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Andrew B. Meadows, PharmD, MHA, BCPS, FACHE, is a Major in the U.S. Air Force and a student at the Air Command and Staff College, Maxwell Air Force Base, Ala. Lucinda L. Maine, PhD, is Executive Vice President, American Association of Colleges of Pharmacy, Alexandria, Va. Elizabeth K. Keyes is Senior Director, Strategic Alliances and Business Development, American Pharmacists Association, Washington, D.C. Kathy Pearson, MS, PhD, is Director, Health Care Management Programs, Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia. Kenn Finstuen, MSc, MEd, PhD, is Professor, Health Care Administration, U.S. Army–Baylor University Graduate Program in Health Care Administration, U.S. Army Medical Department, Fort Sam Houston, Tex. Correspondence: Maj. Andrew B. Meadows, PharmD, MHA, BCPS, FACHE, Student, Air Command and Staff College, 225 Chennault Circle, Maxwell AFB, AL 36112. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in the article, including grants, employment, gifts, stock holdings, or honoraria. The opinions expressed herein by Maj. Meadows and Dr. Finstuen are strictly their own and do not reflect the official policy or position of the U.S. Government or its Departments of the Air Force, Army, and Defense.
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M
edications have become an integral element of disease management and patient care. This focus on pharmacologic treatment in the evolving health care world creates challenges for pharmacy professionals. The challenges that lie ahead must be successfully overcome to direct the profession in a way that is mutually beneficial for patients and professionals. In a profession accustomed to change, success will depend on the capabilities of pharmacy executives in all practice settings to identify and meet these challenges. Unfortunately, topics such as management and leadership have not been frequently addressed in the pharmacy literature. Since Hepler and Strand’s1 call for pharmaceutical care and the national acceptance of the doctor of pharmacy as the entry-level professional degree, pharmacy’s focus has been on patient care and clinical skills. Other professions, including nursing2 and medicine,3,4 have been studied to determine the current and future needs of executives in their respective professions. Results indicate that executives, regardless of their profession or practice setting,
AT A GLANCE Synopsis: In this follow-up to a May/June 2003 JAPhA study that explored opinions of military pharmacists, private-sector pharmacy executives participating in a Delphi method study identified pharmacy leadership, finance, and workforce issues likely to present challenges in the future. Respondents rated issues in the pharmacy leadership area as most important. The skills (technical expertise), knowledge (possession of facts and principles), and abilities (physical, mental, or legal powers) needed to successfully manage these challenges reflected the difficulties of managing a professional department in an era of instability, volatility, and uncertainty: ability to see the big picture, ability to demonstrate the value of pharmacy services, ability to lead and manage in an ethical manner, skills in influencing senior leadership within an organization, and ability to keep these senior leaders fully informed about pharmacy financial matters. Analysis: The pharmacists’ role in maximizing positive health outcomes through medication management and patient care has received much attention since Hepler and Strand’s 1990 article defining pharmaceutical care and the profession’s decision to establish the doctor of pharmacy as the entry-level degree. While the pharmacist–clinician is clearly needed in front-line professional positions, those serving in executive practice positions must acquire the skills, knowledge, and abilities to advocate for appropriate and necessary resources to maintain a safe, accurate, and efficient drug use system and advance the pharmacist’s role in direct patient care.
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require competence in a wide array of leadership and management skills. A strong background in human relations has also been cited as beneficial. Being business-focused (personnel management, finances, goal setting, problem solving) is also suggested by other health care professionals as a requirement for success as an executive. A strong sense of values and professional ethics is an additional need. Until recently, equivalent research was absent in the world of pharmacy. In the May/June 2003 issue of Journal of the American Pharmacists Association,5 pharmacy’s first Delphi study of executive abilities was published. The study was performed and targeted to pharmacy executives in the U.S. Department of Defense (DoD). Identified ability needs were found in the areas of human resources, pharmacy operations/business practices, information management and technology, financial resources, formulary management, drug therapy management, pharmacy benefit management, and leadership. The results, while targeted to pharmacists, are not directly comparable with pharmacists in other settings because of the unique practice settings provided by DoD. The Delphi study reported in this article is the first empirical assessment of issues facing future public-sector pharmacy executives. This study was conducted to gain insight into the required skills, knowledge, and abilities (SKAs) of pharmacy executives in a wide variety of public- and private-sector pharmacy practice settings.
Objectives Our objectives were to identify issues or problems that current and aspiring pharmacy executives will face in the future and to define the SKAs these leaders will need to successfully address those issues. Skills indicate technical expertise, knowledge refers to the possession of facts and principles, and abilities designate physical, mental, or legal powers.
Methods Delphi Round 1—Issues Graduates from the GlaxoSmithKline Executive Management Program for Pharmacy Leaders in 2000, 2001, and 2002 were chosen as study respondents based on their demonstrated expertise in managing complex organizations. The GlaxoSmithKline Executive Management Program for Pharmacy Leaders is cosponsored by the American Pharmacists Association (APhA). APhA lends its expertise to the program through curriculum development and involvement with candidate selection. Not only do these candidates have records of excellence, they have performed at high levels for extended periods of time; in fact, the eligibility criteria for the program require at least 5 years of experience in a leadership role.6 Based on both expertise and tenure, the respondents are clearly deserving of the designation of pharmacy executive. We ran two iterations of the Delphi method for executive deciwww.japha.org
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sion making separated by an expert panel content analysis. The Delphi method was originally developed by the RAND Corporation7–10 and has been employed in several health care settings to establish priorities and predict emerging trends.11–13 In the first round of the Delphi method, participants were asked to identify five major issues they believed would be of greatest importance to pharmacy leaders in the next 5 to 10 years. Respondents were also asked to name specific SKAs that might be needed by future leaders to successfully deal with those issues. The Delphi method uses an open-ended questioning format in the first round. To hasten the response time for this study, e-mail was used for all communication with respondents, including instrument delivery. For ethical reasons, the anonymity of respondents is absolutely essential, and this was maintained at all points during the research process by cutting and pasting respondents’ electronic responses into a single word processing document. Names, addresses, or other contact information were not retained. The original electronic response was subsequently deleted. An environment of nonattribution was essential to the viability of this study. From the e-mail responses received in the first round, major issues and SKAs were compiled. The complete list of issues was scanned for key phrases, and the frequencies with which the phrases appeared were calculated. The investigators, using key phrases as sorting criteria, sorted responses into like categories. Analysis of Issues—Domains
Next, an expert panel—comprising four pharmacy executives who are widely considered leaders in the profession in a variety of settings, including academia, community practice, pharmacy benefit management, and professional association management—was convened during an APhA annual meeting. Collectively, this panel represented more than 100 combined years of practice and leadership experience in the pharmacy profession. The panel reviewed the issues generated during the first round of the Delphi, sorted them into a set of meaningful domain categories, and selected an appropriate title for each domain. Finally, the expert panel rankordered the domains according to the total number of issues they assigned to that domain. None of the authors of this manuscript served as a member of the expert panel. Content validity was assured in this study through the use of this expert panel. Construct validity was ensured by replicating the data collection methods, techniques, and analyses that had been effectively employed in several published studies.14–21
Delphi Round 2—SKA Ratings Results of the first round and expert panel process were provided as feedback to the executive respondents during the second round of the Delphi process, during which the 110 pharmacy executives in the original group (both respondents and nonrespondents) were sent structured questionnaires and asked to rate the importance of all SKAs in each domain identified by the expert panel. As in the first round, the second Delphi round was conducted via e-mail. Vol. 45, No. 1
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The intent of collecting SKAs in round 1 was to form a pool of job requirement items for each issue domain. No attempt was made to modify or standardize these statements. This capture of pharmacy “job language” is thought to provide the most accurate representation of peer thinking. During the second round, respondents were asked to provide relative importance ratings for the SKA items within each of the domains using a 7-point relative scale, ranging from 1, extremely unimportant, to 7, extremely important. Background and demographic data, including age, gender, practice setting, job title, job experience, and education were also collected during the second round. The scale data were analyzed using SPSS for Windows (Chicago, Ill.). Indices of interrater reliability and descriptive statistics were computed for each of the domains and SKA items. Reliability is a concern in any research based on measurement. Internal consistency and interrater reliability were measured using Cronbach’s coefficient alpha22 to establish the extent to which the same results would be obtained from another study sample. Reliability measures were calculated to determine if the average ratings computed for SKAs within specific domains are stable and agreed upon by pharmacy executives.
Results Delphi Round 1—Issue Identification During the first round of the Delphi, 24 of 110 executive participants returned open-ended e-mail questionnaires, resulting in a response rate of 21.8%, a rate considered adequate compared with rates reported in similar studies.14–21 More than 100 issue statements were identified from the responses, which, after combining multiple issues listed by two or more respondents, resulted in 49 unique issues facing pharmacy executives. One of our pharmacist investigators (ABM) then grouped the issue statements, ordered by reported frequency, into a preliminary working list of nine loosely homogeneous content categories: (1) human resources, (2) cost/budget, (3) quality, (4) clinical, (5) professional role, (6) information technology, (7) cognitive services, (8) drug shortages, and (9) miscellaneous. This preliminary list was presented to the expert panel and was used as a starting point for their content deliberations.
Content Analysis of Issues and Domain Definition Table 1 displays the final list of issues and corresponding response frequencies developed by the pharmacy expert panel. After inspecting and reviewing the field-generated issues secured during round 1 of the Delphi process, the panel split several items into two or more statements, and a few separate issues were combined into single issues. The resulting 52 unique issues were then sorted into 5 domain categories: (1) management and development of the pharmacy workforce, (2) pharmacy finance, (3) total quality management of workflow systems, (4) influences on the practice of pharmacy, and Journal of the American Pharmacists Association
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Table 1. Pharmacy Issues as Categorized into Domains by Expert Panel No. Respondents
Issue
No. Respondents
Issue
I. Management and Development of the Pharmacy Workforce (15 unique issues) Dealing with the pharmacist shortage
16
Utilization of resources
1
Recruiting and retaining quality staff
4
Credentialing and privileging
1 1
Increased use of pharmacy
automationa
3
Patient charting skills
Enhancement of clinical information systemsa
3
Development of specialized pharmacists
1
Training for management staff
2
Management of biotechnology drugsa
1
Managing increasing workload with smaller staff
2
Better communication between pharmacistsa
1
Staff management
2
Dealing with new pharmacy graduates
1
Pharmacy workflow
1
II. Pharmacy Finance (12 unique issues) Management of increasing medication costs
8
Forecasting drug expenses
2
Payment for cognitive and patient care services
6
Decreasing margins
2
Reimbursement changes
4
Dealing with pharmacy benefit management
1
Managing the pharmacy budget
3
Manufacturer contracts and rebates
3
Management of biotechnology drugsa
1
Compensation/benefits issues
2
Physician detailing programs
1
Current and future revenue
1
companiesa
III. Total Quality Management of Workflow Systems (13 unique issues) Reducing medication errors
5
Better connecting the pharmacist to the patient
1
Measuring effectiveness of pharmacy services
3
Consumer education
1
Pharmaceutical care
3
Clinical pathway development
1
Increased use of pharmacy automationa
3
Improving quality of care
1
Enhancement of clinical information systemsa
3
Meeting the challenge of medication compliance
1
Patient safety
2
Medical staff involvement in formulary decisions
1
Benchmarking
2
IV. Influences on the Practice of Pharmacy (11 unique issues) Dealing with drug shortages
5
Union issues
1
Evolving role of the pharmacist
4
Nursing shortage
1
E-business
1
Community access to medical care
1
Competing health care professionals
1
Regulatory and legislative initiatives
1
Dealing with pharmacy benefit management
1
Management of biotechnology drugsa
1
companiesa Implementation of federal privacy laws and
1
regulations V. Professional Pharmacy Leadership (7 unique issues) Protecting the future of the profession
2
Better communication between pharmacistsa
1
Influencing change in the pharmacy benefit
1
Acceptance of pharmacists as providers
1
Curriculum needs at the schools of pharmacy
1
Pharmacy organizations must act in unison
1
Ethical issues in establishing drug use criteria
1
aDenotes
issues sorted into more than one domain by the expert panel.
(5) professional pharmacy leadership.
Delphi Round 2—SKA Ratings In the second round of the Delphi, 20 of 110 field participants 58
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returned e-mail questionnaires about the items listed in the above 5 domains (response rate, 18.2%; lower than round 1 but still regarded as sufficient14–21). Demographic and background data were collected during this round (Table 2). On average, executives were 43 years old with nearly 18 years of pharmacy experience in www.japha.org
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a variety of practice settings. Executives were equally distributed between men and women. The majority of respondents (62%) currently held jobs titled “director of pharmacy.” About one half of the respondents reported having earned a master’s degree, and 29% held a doctor of pharmacy degree. Collectively, the respondents had executive-level experience, combined with considerable academic preparation, required to function in a variety of pharmacy leadership positions. Executives evaluated 80 SKA items using the 7-point relative rating scale. Interrater reliability was assessed using Cronbach’s coefficient alpha (Table 3). Reliability indices for individual domains ranged from a high of .87 for the pharmacy finance domain to a low of .68 for the influences on the practice of pharmacy domain. A Cronbach coefficient alpha of .95 was obtained (computed across all 80 items, irrespective of domain). All Cronbach coefficients approached or exceeded the recommended value of .70.22 Overall, these results indicate a high degree of internal consistency for SKA ratings and were interpreted as evidence that average SKA ratings within specific domains were stable and reflected a high level of agreement among the pharmacy executive raters. All SKA items were rated as being important overall, with mean values exceeding the midpoint of the scale. On the 7-point rating scale used, 27 of the 80 SKAs had average ratings above 6.0, and average ratings ranged from 4.10 to 6.67. Table 4 shows the top 3 rated SKA items in each domain. The professional pharmacy leadership domain contained the three items with the highest SKA averages: ability to see the big picture (mean rating, 6.67); ability to demonstrate the value of pharmacy services (mean rating, 6.62); and ability to lead and manage in an ethical manner (mean rating, 6.57). All remaining domain item means were also above a scale value of 6.0, with the exception of the averages of the three items in the influences on the practice of pharmacy domain. Table 5 shows the means and standard deviations for the top 15 rated SKAs. The single highest-rated SKA, ability to see the big picture, along with 4 other top 15 rated SKAs came from the professional pharmacy leadership domain. The pharmacy finance
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Table 2. Demographic Characteristics of Pharmacy Executive Respondents Participating in Delphi Round 2 Mean ± SD
Variable
No. Respondents (%)
43.10 ± 8.34
Age (years) Experience
17.81 ± 8.49
Years as pharmacist Years in current position
4.95 ± 2.46
Gender Men
11 (55.00)
Women
9 (45.00)
Practice setting Institutional public
5 (25.00)
Institutional private
4 (20.00)
Managed care
4 (20.00)
Community chain
2 (10.00)
Mail service
2 (10.00)
Other
3 (15.00)
Job title/position Director of pharmacy
13 (61.91)
Pharmacy manager
2 (9.52)
Clinical pharmacist
1 (4.76)
Assistant director
1 (4.76)
Other
4 (19.05)
Degrees obtained Bachelors (BS in Pharmacy)
19 (90.48)
Masters (MS, MHA, MBA)
9 (42.86)
Doctor of pharmacy (PharmD)
6 (28.57)
Masters (MS in Pharmacy)
2 (9.52)
Doctor of philosophy (PhD)
1 (4.76)
Other
3 (14.29)
Abbreviation used: SD, standard deviation.
Table 3. SKA Item Allocations and Interrater Reliability Indices by Domain and Overall in Delphi Round 2
Domain Management and development of the pharmacy workforce
No. Rated SKA Items
% SKA Items
Cronbach’s Alphaa
20
25.0
.73
Pharmacy finance
20
25.0
.87
Total quality management of workflow systems
20
25.0
.85
Influences on the practice of pharmacy
10
12.5
.68
Professional pharmacy leadership
10
12.5
.82
All items
80
100
.95
Abbreviation used: SKA, skills, knowledge, and abilities. aAll
Cronbach alpha coefficients approached or exceeded the recommended value of .70, and represent stable internally consistent measures of the item means within domains.22
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Table 4. Descriptive Statistics for the Top 3 Rated SKAs in Each Domain in Delphi Round 2 Domain
SKA Item
Mean ± SDa
Management and development of the
1. Ability to adapt to change
6.38 ± 0.67
pharmacy workforce
2. Skills in building a positive work environment for staff
6.38 ± 0.74
3. Skills in communicating with all possible stakeholders
6.33 ± 0.66
1. Ability to keep senior leadership fully informed
6.43 ± 0.81
2. Skills in recognizing cost saving opportunities
6.38 ± 0.59
3. Skills in both written and verbal communication
6.33 ± 0.97
Total quality management of
1. Skills in analyzing complex problems and situations
6.38 ± 0.80
workflow systems
2. Ability to critically evaluate information and proposals
6.33 ± 0.86
3. Ability to collaborate with other health care professionals
6.10 ± 0.94
1. Ability to anticipate product usage levels
5.76 ± 0.83
2. Knowledge of federal privacy law implications for pharmacy
5.76 ± 1.30
3. Ability to budget for cost overruns
5.71 ± 0.72
Pharmacy finance
Influences on the practice of pharmacy
Professional pharmacy leadership
1. Ability to see the big picture
6.67 ± 0.80
2. Ability to demonstrate the value of pharmacy services
6.62 ± 0.59
3. Ability to lead and manage in an ethical manner
6.57 ± 0.60
Abbreviations used: SD, standard deviation; SKA, skills, knowledge, and abilities. aRespondents
rated items on a 7-point scale, ranging from 1, extremely unimportant, to 7, extremely important.
domain and the management and development of the pharmacy workforce domain each accounted for 4 of the top 15 items. The total quality management of workflow systems domain accounted for the remaining 2 SKA items. Interrater agreement is again reflected by inspection of rating standard deviations; none was greater than 1 rating scale point.
In contrast, Table 6 displays the means and standard deviations for the bottom 10 rated SKAs in all domains. The lowest-rated SKA was knowledge of ethical issues related to gene therapy from the pharmacy finance domain (mean rating, 4.10). While these item averages were about 2 scale points lower than the averages reported in Table 5, all were still above the neutral point (scale
Table 5. Descriptive Statistics for the Top 15 Rated SKAs in Delphi Round 2 SKA Item
Mean ± SDa
Domain
1. Ability to see the big picture
Professional pharmacy leadership
6.67 ± 0.80
2. Ability to demonstrate the value of pharmacy services
Professional pharmacy leadership
6.62 ± 0.59
3. Ability to lead and manage in an ethical manner
Professional pharmacy leadership
6.57 ± 0.60
4. Skills in influencing senior leadership within organization
Professional pharmacy leadership
6.48 ± 0.75
5. Ability to keep senior leadership fully informed
Pharmacy finance
6.43 ± 0.81
6. Skills in recognizing cost saving opportunities
Pharmacy finance
6.38 ± 0.59
7. Ability to adapt to change pharmacy workforce
Management and development of the
6.38 ± 0.67
8. Skills in building a positive work environment for staff pharmacy workforce
Management and development of the 6.38 ± 0.74
9. Skills in analyzing complex problems and situations 10. Skills in communicating with all possible stakeholders pharmacy workforce
Total quality management of workflow systems
6.38 ± 0.80
Management and development of the 6.33 ± 0.66
11. Ability to critically evaluate information and proposals
Total quality management of workflow systems
6.33 ± 0.86
12. Skills in both written and verbal communication
Pharmacy finance
6.33 ± 0.97 6.24 ± 0.83
13. Skills in interpersonal relations
Professional pharmacy leadership
1 4. Ability to actively listen pharmacy workforce
Management and development of the 6.19 ± 0.81
15. Ability to allocate scarce financial resources
Pharmacy finance
6.19 ± 0.87
Abbreviation used: SD, standard deviation; SKA, skills, knowledge, and abilities. aRespondents
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rated items on a 7-point scale, ranging from 1, extremely unimportant, to 7, extremely important.
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value of 4) of the 7-point rating scale. Compared with the top-rated SKAs, the standard deviations of ratings for low-rated SKAs were all greater than 1 rating scale point, ranging from 1.1 to 1.7, indicative of more variability or disagreement among respondents.
Discussion Today’s roles and responsibilities of pharmacist practitioners and practice leaders are markedly different than those common in the past. As noted by Hudak and colleagues,23 leaders of health care organizations are experiencing times of “financial instability, organizational volatility and management uncertainty.” Certainly pharmacy’s leaders are no exception. Not surprisingly then, the SKAs given the highest importance ratings were those that reflected the need for vision, ethics, and the ability to communicate to external stakeholders effectively. Five of the top 15 SKAs—and all four of the highest-rated items—came from the professional pharmacy leadership domain. The ability to see the big picture, interpersonal relations, and the ability to demonstrate the value of pharmacy services were among the toprated SKA items. The respondents in this Delphi study were accomplished pharmacy executives from diverse sectors of contemporary pharmacy practice. Nonetheless, their responses were notable for their consistency. The issues identified by these executives in round 1 of the Delphi were strikingly similar to those identified in a previous study5 of DoD pharmacy executives and of several studies of nonpharmacy executive participants.14–21 Dealing with workforce shortages, financing issues, and automation were among the most frequently reported issues challenging contemporary pharmacy executives. Nine of the top 15 SKAs in this study were also among the top
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15 identified in the DoD study, with ability to see the big picture identified by both sets of respondents as the most important SKA. In addition, effective communication with key stakeholders (written, verbal, and listening skills) and critical thinking and problem solving rated very high in importance by both groups of pharmacy executives. During round 1 of the Delphi, the issues identified as confronting pharmacy executives were markedly focused on things internal to pharmacy operations. Dealing with the pharmacist shortage, prescription drug cost increases and shortages, and increased use of pharmacy automation are examples of top mentions in the initial round of responses. However, in rating the SKAs in the second round, respondents clearly placed more emphasis and importance on pharmacy leaders’ external focus and communications abilities. As in previous studies, the lowest-rated items were those that are technical in nature, including use of clinical practice guidelines, understanding the FDA drug approval process, and managing complex formulary models. As medication use commands increasing attention within health care organizations and during health policy debates, this combination of visionary ability, communications, human resources management, and external focus are even more critical for effective pharmacy leadership and management. Advocating for the appropriate and necessary resources to not only maintain a safe, accurate, and efficient drug use system while simultaneously advancing pharmacists’ role in direct patient care calls upon all these skills and abilities. This analysis begs further evaluation of how management and leadership skills are currently incorporated into the professional doctoral degree program and postgraduate education and training, including residencies. Pharmacy students are certainly required to develop team-oriented communication and problem-solving skills in today’s active learning approaches to professional pharmacy
Table 6. Descriptive Statistics for the Bottom 10 Rated SKAs in Delphi Round 2 SKA Item
Domain
Mean ± SDa
71. Ability to effectively use expert consultants
Pharmacy finance
5.24 ± 1.34
72. Knowledge of managed care cost terminology
Pharmacy finance
5.19 ± 1.12
73. Knowledge of statistical analysis
Total quality management of workflow systems
5.14 ± 1.20
74. Ability to effectively lobby lawmakers
Professional pharmacy leadership
5.00 ± 1.22
75. Ability to build relationships with colleges of pharmacy
Management and development of the pharmacy workforce
4.90 ± 1.26
76. Skills in developing clinical practice guidelines
Total quality management of workflow systems
4.90 ± 1.26
77. Skills in career management and planning
Management and development of the pharmacy workforce
4.76 ± 1.04
78. Skills in leading development of “city-wide” formularies
Total quality management of workflow systems
4.48 ± 1.72
79. Knowledge of the FDA’s drug approval process
Pharmacy finance
4.38 ± 1.24
80. Knowledge of ethical issues related to gene therapy
Pharmacy finance
4.10 ± 1.22
Abbreviation used: FDA, Food and Drug Administration; SD, standard deviation; SKA, skills, knowlege, and abilities. aRespondents
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education. More than one fourth of the curriculum is experiential, requiring team work with nonpharmacy personnel. Both didactic and experiential emphases are critical to building the next generation of effective pharmacy leadership. However, many would agree that in our efforts to provide graduates with the fundamentals of pharmacotherapy and thereby create clinicians equipped to deliver patient-focused, evidence-based care, sufficient emphasis on leadership and advanced management skills is lacking. Providing postgraduate opportunities to develop executive leadership skills is essential. Similarly, strong mentoring programs are vitally important. Future research could include the assessment of perceptions of emerging pharmacy leaders regarding the issues and the highly rated SKAs developed by the executives in this study. This would enable delineation of focus areas for the professional development of emerging leaders. Additionally, more detailed investigation of specific practice settings (i.e., institutional public versus mail service) may provide useful insights regarding the challenges that executives face across practice settings.
Limitations Limitations of this study include the low response rate and small sample size. While the response rate observed is considered sufficient based on comparable research, the input from more that one half of the sample of pharmacy executives was not captured. The degree of agreement among responders makes it unlikely that additional data provided by nonresponders would have dramatically altered the results. However, more responses would have been valuable and might have strengthened our findings. A larger sample size would also have been desirable and would have strengthened the power and generalizability of the results.
Conclusion Through successful integration of communication skills, critical thinking, and problem solving techniques, future public-sector pharmacy executives will be better equipped to effectively position their organizations and the profession for the challenges that lie ahead. Pharmacy executives who participated in this Delphi process rated highly several leadership abilities, including ability to see the big picture, demonstrate the value of pharmacy services, lead and manage in an ethical manner, and influence senior leaders in an organization. Combined with communications skills needed to convey pharmacy’s financial needs to senior managers, these capabilities should be the focus of postgraduate training and education activities for pharmacists seeking careers in pharmacy management in practice settings. Pharmacy certainly remains a patient-focused profession at all levels of service, whether pharmacist-clinician based practice or pharmacy management at the executive level. However, the means of supporting this effort may vary 62
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by practice setting. Pharmacy executives must advocate for appropriate and necessary resources to maintain a safe, accurate, and efficient drug use system and advance the pharmacist’s role in direct patient care.
References 1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–43. 2. O’Leary J, O’Leary P. What is the future for nurse executives? Nurs Adm Q. 1999;23:4–10. 3. Hudak RP, Brooke PP Jr., Finstuen K, Trounson J. Management competencies for medical practice executives: skills, knowledge and abilities required for the future. J Health Adm Educ. 1997;15:219–39. 4. William SJ. What skills do physician leaders need now and in the future? Physician Exec. 2001;27:46–8. 5. Meadows AB, Finstuen K, Hudak RP. Pharmacy executives: leadership issues and associated skills, knowledge, and abilities in the U.S. Department of Defense. J Am Pharm Assoc. 2003;43:412–8. 6. University of Pennsylvania Web site. GlaxoSmithKline executive management program for pharmacy leaders. Accessed at pharmacy leaders.net, November 30, 2004. 7. Helmer O. Analysis of the future: the Delphi method. Santa Monica, Calif.: RAND Corporation; 1967. Report P-3558. 8. Brown B, Cochran S, Dalkey N. The Delphi method II: structure of experiments. Santa Monica, Calif.: RAND Corporation; 1969. Report RM-5957PR. 9. Dalkey NC. The Delphi method: an experimental study of group opinion. Santa Monica, Calif.: RAND Corporation; 1969. Report RM-5888-PR. 10. Delbecq AL, Van de Ven AH, Gustafson DH. Group techniques for program planning: a guide to nominal group and Delphi processes. Glenview, Ill.: Scott Foresman; 1975. 11. American College of Healthcare Executives. Health care in the 1990s: trends and strategies. Ann Arbor, Mich.: Health Administration Press; 1984. 12. American College of Healthcare Executives. The future of healthcare: change and choice. Ann Arbor, Mich.: Health Administration Press; 1987. 13. American College of Healthcare Executives. The future of healthcare: physician and hospital relationships. Ann Arbor, Mich.: Health Administration Press; 1991. 14. Hudak RP, Brooke PP, Finstuen K. Forecast 2000: a prediction of skills, knowledge, and abilities required by senior medical treatment facility leaders into the 21st century. Mil Med. 1994;159:494–500. 15. Sentell JW, Finstuen K. Executive skills 21: a forecast of leadership skills and associated competencies required by naval hospital administrators into the 21st century. Mil Med. 1998;163:3–8. 16. Rogers JR, Finstuen K, Manglesdorff AD, Snyder GL. Executive competencies and skills required by United States Coast Guard health care administrators. AAMA Executive. 1998(winter):10–5. 17. Mangelsdorff AD, Rodgers JR, Zucker KW et al. Vision 21 Delphi Panel: Senior Army Medical Service Corps officers’ vision of behaviors for success of future Medical Service Corps officers. Mil Med. 1996;162:450–2. 18. Hudak RP, Brooke PP, Finstuen K, Riley P. Health care administration in the year 2000: practitioners’ views of future issues and job requirements. Hosp Health Serv Adm. 1993;38:181–95. 19. Brooke PP, Hudak RP, Finstuen K, Trounson J. Management competencies required in ambulatory care settings. Physician Exec. 1998;24:32–8. 20. Wineman JA, Mangelsdorff AD, Finstuen K. Senior executive behaviors for the Army dental care system of the 21st century. Mil Med. 1998;163:377–80. 21. Peters AD, Dominguez DG, Finstuen K. Vision 2005: a forecast of executive leadership skills and associated competencies required by Navy Dental Corps officers into the 20th century. Navy Med. 2000;92:10–5. 22. Nunnally JC. Psychometric theory, 2nd ed. New York: McGraw-Hill; 1978. 23. Hudak RP, Brooke PP, Finstuen K. Identifying management competencies for health care executives: review of a series of Delphi studies. J Health Adm Educ. 2000;18:213–43.
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Pharmacy Executive Leadership Issues and Associated Skills, Knowledge, and Abilities Andrew B. Meadows, Lucinda L. Maine, Elizabeth K. Keyes, Kathy Pearson, and Kenn Finstuen
Received November 7, 2003, and in revised form March 29, 2004. Accepted for publication May 4, 2004.
ABSTRACT Objectives: To identify challenges that current and future pharmacy executives are facing or will face in the future and to define what skills, knowledge, and abilities (SKAs) are required to successfully negotiate these challenges. Design: Delphi method for executive decision making. Setting: Civilian pharmacy profession. Participants: 110 pharmacists who graduated from the GlaxoSmithKline Executive Management Program for Pharmacy Leaders. Interventions: Two iterations of the Delphi method for executive decision making separated by an expert panel content analysis. Main Outcome Measures: Round 1—participants were asked to identify five major issues they believed to be of greatest importance to pharmacy leaders in the next 5–10 years and name specific SKAs that might be needed by future leaders to successfully deal with those issues. An expert panel reviewed the issues, classified issues into specific domains, and titled each domain. Round 2—participants rated the SKAs on a 7-point scale according to their individual assessment of importance in each domain. Results: For Delphi rounds 1 and 2, response rates were 21.8% and 18.2%, respectively. More than 100 total issue statements were identified. The expert panel sorted the issues into five domains: management and development of the pharmacy workforce, pharmacy finance, total quality management of workflow systems, influences on the practice of pharmacy, and professional pharmacy leadership. Five of the top 15 SKAs—and all four highest ranked items— came from the professional pharmacy leadership domain, including ability to see the big picture, ability to demonstrate the value of pharmacy services, ability to lead and manage in an ethical manner, and skills for influencing an organization’s senior leadership. Conclusion: Through successful integration of communication skills, critical thinking, and problem solving techniques, future public-sector pharmacy executives will be better equipped to effectively position their organizations and the profession for the challenges that lie ahead. Keywords: Delphi method, future, leadership, competency, professional development, pharmacists. J Am Pharm Assoc. 2005;45:55–62.
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Andrew B. Meadows, PharmD, MHA, BCPS, FACHE, is a Major in the U.S. Air Force and a student at the Air Command and Staff College, Maxwell Air Force Base, Ala. Lucinda L. Maine, PhD, is Executive Vice President, American Association of Colleges of Pharmacy, Alexandria, Va. Elizabeth K. Keyes is Senior Director, Strategic Alliances and Business Development, American Pharmacists Association, Washington, D.C. Kathy Pearson, MS, PhD, is Director, Health Care Management Programs, Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia. Kenn Finstuen, MSc, MEd, PhD, is Professor, Health Care Administration, U.S. Army–Baylor University Graduate Program in Health Care Administration, U.S. Army Medical Department, Fort Sam Houston, Tex. Correspondence: Maj. Andrew B. Meadows, PharmD, MHA, BCPS, FACHE, Student, Air Command and Staff College, 225 Chennault Circle, Maxwell AFB, AL 36112. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in the article, including grants, employment, gifts, stock holdings, or honoraria. The opinions expressed herein by Maj. Meadows and Dr. Finstuen are strictly their own and do not reflect the official policy or position of the U.S. Government or its Departments of the Air Force, Army, and Defense.
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M
edications have become an integral element of disease management and patient care. This focus on pharmacologic treatment in the evolving health care world creates challenges for pharmacy professionals. The challenges that lie ahead must be successfully overcome to direct the profession in a way that is mutually beneficial for patients and professionals. In a profession accustomed to change, success will depend on the capabilities of pharmacy executives in all practice settings to identify and meet these challenges. Unfortunately, topics such as management and leadership have not been frequently addressed in the pharmacy literature. Since Hepler and Strand’s1 call for pharmaceutical care and the national acceptance of the doctor of pharmacy as the entry-level professional degree, pharmacy’s focus has been on patient care and clinical skills. Other professions, including nursing2 and medicine,3,4 have been studied to determine the current and future needs of executives in their respective professions. Results indicate that executives, regardless of their profession or practice setting,
AT A GLANCE Synopsis: In this follow-up to a May/June 2003 JAPhA study that explored opinions of military pharmacists, private-sector pharmacy executives participating in a Delphi method study identified pharmacy leadership, finance, and workforce issues likely to present challenges in the future. Respondents rated issues in the pharmacy leadership area as most important. The skills (technical expertise), knowledge (possession of facts and principles), and abilities (physical, mental, or legal powers) needed to successfully manage these challenges reflected the difficulties of managing a professional department in an era of instability, volatility, and uncertainty: ability to see the big picture, ability to demonstrate the value of pharmacy services, ability to lead and manage in an ethical manner, skills in influencing senior leadership within an organization, and ability to keep these senior leaders fully informed about pharmacy financial matters. Analysis: The pharmacists’ role in maximizing positive health outcomes through medication management and patient care has received much attention since Hepler and Strand’s 1990 article defining pharmaceutical care and the profession’s decision to establish the doctor of pharmacy as the entry-level degree. While the pharmacist–clinician is clearly needed in front-line professional positions, those serving in executive practice positions must acquire the skills, knowledge, and abilities to advocate for appropriate and necessary resources to maintain a safe, accurate, and efficient drug use system and advance the pharmacist’s role in direct patient care.
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require competence in a wide array of leadership and management skills. A strong background in human relations has also been cited as beneficial. Being business-focused (personnel management, finances, goal setting, problem solving) is also suggested by other health care professionals as a requirement for success as an executive. A strong sense of values and professional ethics is an additional need. Until recently, equivalent research was absent in the world of pharmacy. In the May/June 2003 issue of Journal of the American Pharmacists Association,5 pharmacy’s first Delphi study of executive abilities was published. The study was performed and targeted to pharmacy executives in the U.S. Department of Defense (DoD). Identified ability needs were found in the areas of human resources, pharmacy operations/business practices, information management and technology, financial resources, formulary management, drug therapy management, pharmacy benefit management, and leadership. The results, while targeted to pharmacists, are not directly comparable with pharmacists in other settings because of the unique practice settings provided by DoD. The Delphi study reported in this article is the first empirical assessment of issues facing future public-sector pharmacy executives. This study was conducted to gain insight into the required skills, knowledge, and abilities (SKAs) of pharmacy executives in a wide variety of public- and private-sector pharmacy practice settings.
Objectives Our objectives were to identify issues or problems that current and aspiring pharmacy executives will face in the future and to define the SKAs these leaders will need to successfully address those issues. Skills indicate technical expertise, knowledge refers to the possession of facts and principles, and abilities designate physical, mental, or legal powers.
Methods Delphi Round 1—Issues Graduates from the GlaxoSmithKline Executive Management Program for Pharmacy Leaders in 2000, 2001, and 2002 were chosen as study respondents based on their demonstrated expertise in managing complex organizations. The GlaxoSmithKline Executive Management Program for Pharmacy Leaders is cosponsored by the American Pharmacists Association (APhA). APhA lends its expertise to the program through curriculum development and involvement with candidate selection. Not only do these candidates have records of excellence, they have performed at high levels for extended periods of time; in fact, the eligibility criteria for the program require at least 5 years of experience in a leadership role.6 Based on both expertise and tenure, the respondents are clearly deserving of the designation of pharmacy executive. We ran two iterations of the Delphi method for executive deciwww.japha.org
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sion making separated by an expert panel content analysis. The Delphi method was originally developed by the RAND Corporation7–10 and has been employed in several health care settings to establish priorities and predict emerging trends.11–13 In the first round of the Delphi method, participants were asked to identify five major issues they believed would be of greatest importance to pharmacy leaders in the next 5 to 10 years. Respondents were also asked to name specific SKAs that might be needed by future leaders to successfully deal with those issues. The Delphi method uses an open-ended questioning format in the first round. To hasten the response time for this study, e-mail was used for all communication with respondents, including instrument delivery. For ethical reasons, the anonymity of respondents is absolutely essential, and this was maintained at all points during the research process by cutting and pasting respondents’ electronic responses into a single word processing document. Names, addresses, or other contact information were not retained. The original electronic response was subsequently deleted. An environment of nonattribution was essential to the viability of this study. From the e-mail responses received in the first round, major issues and SKAs were compiled. The complete list of issues was scanned for key phrases, and the frequencies with which the phrases appeared were calculated. The investigators, using key phrases as sorting criteria, sorted responses into like categories. Analysis of Issues—Domains
Next, an expert panel—comprising four pharmacy executives who are widely considered leaders in the profession in a variety of settings, including academia, community practice, pharmacy benefit management, and professional association management—was convened during an APhA annual meeting. Collectively, this panel represented more than 100 combined years of practice and leadership experience in the pharmacy profession. The panel reviewed the issues generated during the first round of the Delphi, sorted them into a set of meaningful domain categories, and selected an appropriate title for each domain. Finally, the expert panel rankordered the domains according to the total number of issues they assigned to that domain. None of the authors of this manuscript served as a member of the expert panel. Content validity was assured in this study through the use of this expert panel. Construct validity was ensured by replicating the data collection methods, techniques, and analyses that had been effectively employed in several published studies.14–21
Delphi Round 2—SKA Ratings Results of the first round and expert panel process were provided as feedback to the executive respondents during the second round of the Delphi process, during which the 110 pharmacy executives in the original group (both respondents and nonrespondents) were sent structured questionnaires and asked to rate the importance of all SKAs in each domain identified by the expert panel. As in the first round, the second Delphi round was conducted via e-mail. Vol. 45, No. 1
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The intent of collecting SKAs in round 1 was to form a pool of job requirement items for each issue domain. No attempt was made to modify or standardize these statements. This capture of pharmacy “job language” is thought to provide the most accurate representation of peer thinking. During the second round, respondents were asked to provide relative importance ratings for the SKA items within each of the domains using a 7-point relative scale, ranging from 1, extremely unimportant, to 7, extremely important. Background and demographic data, including age, gender, practice setting, job title, job experience, and education were also collected during the second round. The scale data were analyzed using SPSS for Windows (Chicago, Ill.). Indices of interrater reliability and descriptive statistics were computed for each of the domains and SKA items. Reliability is a concern in any research based on measurement. Internal consistency and interrater reliability were measured using Cronbach’s coefficient alpha22 to establish the extent to which the same results would be obtained from another study sample. Reliability measures were calculated to determine if the average ratings computed for SKAs within specific domains are stable and agreed upon by pharmacy executives.
Results Delphi Round 1—Issue Identification During the first round of the Delphi, 24 of 110 executive participants returned open-ended e-mail questionnaires, resulting in a response rate of 21.8%, a rate considered adequate compared with rates reported in similar studies.14–21 More than 100 issue statements were identified from the responses, which, after combining multiple issues listed by two or more respondents, resulted in 49 unique issues facing pharmacy executives. One of our pharmacist investigators (ABM) then grouped the issue statements, ordered by reported frequency, into a preliminary working list of nine loosely homogeneous content categories: (1) human resources, (2) cost/budget, (3) quality, (4) clinical, (5) professional role, (6) information technology, (7) cognitive services, (8) drug shortages, and (9) miscellaneous. This preliminary list was presented to the expert panel and was used as a starting point for their content deliberations.
Content Analysis of Issues and Domain Definition Table 1 displays the final list of issues and corresponding response frequencies developed by the pharmacy expert panel. After inspecting and reviewing the field-generated issues secured during round 1 of the Delphi process, the panel split several items into two or more statements, and a few separate issues were combined into single issues. The resulting 52 unique issues were then sorted into 5 domain categories: (1) management and development of the pharmacy workforce, (2) pharmacy finance, (3) total quality management of workflow systems, (4) influences on the practice of pharmacy, and Journal of the American Pharmacists Association
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Table 1. Pharmacy Issues as Categorized into Domains by Expert Panel No. Respondents
Issue
No. Respondents
Issue
I. Management and Development of the Pharmacy Workforce (15 unique issues) Dealing with the pharmacist shortage
16
Utilization of resources
1
Recruiting and retaining quality staff
4
Credentialing and privileging
1 1
Increased use of pharmacy
automationa
3
Patient charting skills
Enhancement of clinical information systemsa
3
Development of specialized pharmacists
1
Training for management staff
2
Management of biotechnology drugsa
1
Managing increasing workload with smaller staff
2
Better communication between pharmacistsa
1
Staff management
2
Dealing with new pharmacy graduates
1
Pharmacy workflow
1
II. Pharmacy Finance (12 unique issues) Management of increasing medication costs
8
Forecasting drug expenses
2
Payment for cognitive and patient care services
6
Decreasing margins
2
Reimbursement changes
4
Dealing with pharmacy benefit management
1
Managing the pharmacy budget
3
Manufacturer contracts and rebates
3
Management of biotechnology drugsa
1
Compensation/benefits issues
2
Physician detailing programs
1
Current and future revenue
1
companiesa
III. Total Quality Management of Workflow Systems (13 unique issues) Reducing medication errors
5
Better connecting the pharmacist to the patient
1
Measuring effectiveness of pharmacy services
3
Consumer education
1
Pharmaceutical care
3
Clinical pathway development
1
Increased use of pharmacy automationa
3
Improving quality of care
1
Enhancement of clinical information systemsa
3
Meeting the challenge of medication compliance
1
Patient safety
2
Medical staff involvement in formulary decisions
1
Benchmarking
2
IV. Influences on the Practice of Pharmacy (11 unique issues) Dealing with drug shortages
5
Union issues
1
Evolving role of the pharmacist
4
Nursing shortage
1
E-business
1
Community access to medical care
1
Competing health care professionals
1
Regulatory and legislative initiatives
1
Dealing with pharmacy benefit management
1
Management of biotechnology drugsa
1
companiesa Implementation of federal privacy laws and
1
regulations V. Professional Pharmacy Leadership (7 unique issues) Protecting the future of the profession
2
Better communication between pharmacistsa
1
Influencing change in the pharmacy benefit
1
Acceptance of pharmacists as providers
1
Curriculum needs at the schools of pharmacy
1
Pharmacy organizations must act in unison
1
Ethical issues in establishing drug use criteria
1
aDenotes
issues sorted into more than one domain by the expert panel.
(5) professional pharmacy leadership.
Delphi Round 2—SKA Ratings In the second round of the Delphi, 20 of 110 field participants 58
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returned e-mail questionnaires about the items listed in the above 5 domains (response rate, 18.2%; lower than round 1 but still regarded as sufficient14–21). Demographic and background data were collected during this round (Table 2). On average, executives were 43 years old with nearly 18 years of pharmacy experience in www.japha.org
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a variety of practice settings. Executives were equally distributed between men and women. The majority of respondents (62%) currently held jobs titled “director of pharmacy.” About one half of the respondents reported having earned a master’s degree, and 29% held a doctor of pharmacy degree. Collectively, the respondents had executive-level experience, combined with considerable academic preparation, required to function in a variety of pharmacy leadership positions. Executives evaluated 80 SKA items using the 7-point relative rating scale. Interrater reliability was assessed using Cronbach’s coefficient alpha (Table 3). Reliability indices for individual domains ranged from a high of .87 for the pharmacy finance domain to a low of .68 for the influences on the practice of pharmacy domain. A Cronbach coefficient alpha of .95 was obtained (computed across all 80 items, irrespective of domain). All Cronbach coefficients approached or exceeded the recommended value of .70.22 Overall, these results indicate a high degree of internal consistency for SKA ratings and were interpreted as evidence that average SKA ratings within specific domains were stable and reflected a high level of agreement among the pharmacy executive raters. All SKA items were rated as being important overall, with mean values exceeding the midpoint of the scale. On the 7-point rating scale used, 27 of the 80 SKAs had average ratings above 6.0, and average ratings ranged from 4.10 to 6.67. Table 4 shows the top 3 rated SKA items in each domain. The professional pharmacy leadership domain contained the three items with the highest SKA averages: ability to see the big picture (mean rating, 6.67); ability to demonstrate the value of pharmacy services (mean rating, 6.62); and ability to lead and manage in an ethical manner (mean rating, 6.57). All remaining domain item means were also above a scale value of 6.0, with the exception of the averages of the three items in the influences on the practice of pharmacy domain. Table 5 shows the means and standard deviations for the top 15 rated SKAs. The single highest-rated SKA, ability to see the big picture, along with 4 other top 15 rated SKAs came from the professional pharmacy leadership domain. The pharmacy finance
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Table 2. Demographic Characteristics of Pharmacy Executive Respondents Participating in Delphi Round 2 Mean ± SD
Variable
No. Respondents (%)
43.10 ± 8.34
Age (years) Experience
17.81 ± 8.49
Years as pharmacist Years in current position
4.95 ± 2.46
Gender Men
11 (55.00)
Women
9 (45.00)
Practice setting Institutional public
5 (25.00)
Institutional private
4 (20.00)
Managed care
4 (20.00)
Community chain
2 (10.00)
Mail service
2 (10.00)
Other
3 (15.00)
Job title/position Director of pharmacy
13 (61.91)
Pharmacy manager
2 (9.52)
Clinical pharmacist
1 (4.76)
Assistant director
1 (4.76)
Other
4 (19.05)
Degrees obtained Bachelors (BS in Pharmacy)
19 (90.48)
Masters (MS, MHA, MBA)
9 (42.86)
Doctor of pharmacy (PharmD)
6 (28.57)
Masters (MS in Pharmacy)
2 (9.52)
Doctor of philosophy (PhD)
1 (4.76)
Other
3 (14.29)
Abbreviation used: SD, standard deviation.
Table 3. SKA Item Allocations and Interrater Reliability Indices by Domain and Overall in Delphi Round 2
Domain Management and development of the pharmacy workforce
No. Rated SKA Items
% SKA Items
Cronbach’s Alphaa
20
25.0
.73
Pharmacy finance
20
25.0
.87
Total quality management of workflow systems
20
25.0
.85
Influences on the practice of pharmacy
10
12.5
.68
Professional pharmacy leadership
10
12.5
.82
All items
80
100
.95
Abbreviation used: SKA, skills, knowledge, and abilities. aAll
Cronbach alpha coefficients approached or exceeded the recommended value of .70, and represent stable internally consistent measures of the item means within domains.22
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Table 4. Descriptive Statistics for the Top 3 Rated SKAs in Each Domain in Delphi Round 2 Domain
SKA Item
Mean ± SDa
Management and development of the
1. Ability to adapt to change
6.38 ± 0.67
pharmacy workforce
2. Skills in building a positive work environment for staff
6.38 ± 0.74
3. Skills in communicating with all possible stakeholders
6.33 ± 0.66
1. Ability to keep senior leadership fully informed
6.43 ± 0.81
2. Skills in recognizing cost saving opportunities
6.38 ± 0.59
3. Skills in both written and verbal communication
6.33 ± 0.97
Total quality management of
1. Skills in analyzing complex problems and situations
6.38 ± 0.80
workflow systems
2. Ability to critically evaluate information and proposals
6.33 ± 0.86
3. Ability to collaborate with other health care professionals
6.10 ± 0.94
1. Ability to anticipate product usage levels
5.76 ± 0.83
2. Knowledge of federal privacy law implications for pharmacy
5.76 ± 1.30
3. Ability to budget for cost overruns
5.71 ± 0.72
Pharmacy finance
Influences on the practice of pharmacy
Professional pharmacy leadership
1. Ability to see the big picture
6.67 ± 0.80
2. Ability to demonstrate the value of pharmacy services
6.62 ± 0.59
3. Ability to lead and manage in an ethical manner
6.57 ± 0.60
Abbreviations used: SD, standard deviation; SKA, skills, knowledge, and abilities. aRespondents
rated items on a 7-point scale, ranging from 1, extremely unimportant, to 7, extremely important.
domain and the management and development of the pharmacy workforce domain each accounted for 4 of the top 15 items. The total quality management of workflow systems domain accounted for the remaining 2 SKA items. Interrater agreement is again reflected by inspection of rating standard deviations; none was greater than 1 rating scale point.
In contrast, Table 6 displays the means and standard deviations for the bottom 10 rated SKAs in all domains. The lowest-rated SKA was knowledge of ethical issues related to gene therapy from the pharmacy finance domain (mean rating, 4.10). While these item averages were about 2 scale points lower than the averages reported in Table 5, all were still above the neutral point (scale
Table 5. Descriptive Statistics for the Top 15 Rated SKAs in Delphi Round 2 SKA Item
Mean ± SDa
Domain
1. Ability to see the big picture
Professional pharmacy leadership
6.67 ± 0.80
2. Ability to demonstrate the value of pharmacy services
Professional pharmacy leadership
6.62 ± 0.59
3. Ability to lead and manage in an ethical manner
Professional pharmacy leadership
6.57 ± 0.60
4. Skills in influencing senior leadership within organization
Professional pharmacy leadership
6.48 ± 0.75
5. Ability to keep senior leadership fully informed
Pharmacy finance
6.43 ± 0.81
6. Skills in recognizing cost saving opportunities
Pharmacy finance
6.38 ± 0.59
7. Ability to adapt to change pharmacy workforce
Management and development of the
6.38 ± 0.67
8. Skills in building a positive work environment for staff pharmacy workforce
Management and development of the 6.38 ± 0.74
9. Skills in analyzing complex problems and situations 10. Skills in communicating with all possible stakeholders pharmacy workforce
Total quality management of workflow systems
6.38 ± 0.80
Management and development of the 6.33 ± 0.66
11. Ability to critically evaluate information and proposals
Total quality management of workflow systems
6.33 ± 0.86
12. Skills in both written and verbal communication
Pharmacy finance
6.33 ± 0.97 6.24 ± 0.83
13. Skills in interpersonal relations
Professional pharmacy leadership
1 4. Ability to actively listen pharmacy workforce
Management and development of the 6.19 ± 0.81
15. Ability to allocate scarce financial resources
Pharmacy finance
6.19 ± 0.87
Abbreviation used: SD, standard deviation; SKA, skills, knowledge, and abilities. aRespondents
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rated items on a 7-point scale, ranging from 1, extremely unimportant, to 7, extremely important.
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value of 4) of the 7-point rating scale. Compared with the top-rated SKAs, the standard deviations of ratings for low-rated SKAs were all greater than 1 rating scale point, ranging from 1.1 to 1.7, indicative of more variability or disagreement among respondents.
Discussion Today’s roles and responsibilities of pharmacist practitioners and practice leaders are markedly different than those common in the past. As noted by Hudak and colleagues,23 leaders of health care organizations are experiencing times of “financial instability, organizational volatility and management uncertainty.” Certainly pharmacy’s leaders are no exception. Not surprisingly then, the SKAs given the highest importance ratings were those that reflected the need for vision, ethics, and the ability to communicate to external stakeholders effectively. Five of the top 15 SKAs—and all four of the highest-rated items—came from the professional pharmacy leadership domain. The ability to see the big picture, interpersonal relations, and the ability to demonstrate the value of pharmacy services were among the toprated SKA items. The respondents in this Delphi study were accomplished pharmacy executives from diverse sectors of contemporary pharmacy practice. Nonetheless, their responses were notable for their consistency. The issues identified by these executives in round 1 of the Delphi were strikingly similar to those identified in a previous study5 of DoD pharmacy executives and of several studies of nonpharmacy executive participants.14–21 Dealing with workforce shortages, financing issues, and automation were among the most frequently reported issues challenging contemporary pharmacy executives. Nine of the top 15 SKAs in this study were also among the top
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15 identified in the DoD study, with ability to see the big picture identified by both sets of respondents as the most important SKA. In addition, effective communication with key stakeholders (written, verbal, and listening skills) and critical thinking and problem solving rated very high in importance by both groups of pharmacy executives. During round 1 of the Delphi, the issues identified as confronting pharmacy executives were markedly focused on things internal to pharmacy operations. Dealing with the pharmacist shortage, prescription drug cost increases and shortages, and increased use of pharmacy automation are examples of top mentions in the initial round of responses. However, in rating the SKAs in the second round, respondents clearly placed more emphasis and importance on pharmacy leaders’ external focus and communications abilities. As in previous studies, the lowest-rated items were those that are technical in nature, including use of clinical practice guidelines, understanding the FDA drug approval process, and managing complex formulary models. As medication use commands increasing attention within health care organizations and during health policy debates, this combination of visionary ability, communications, human resources management, and external focus are even more critical for effective pharmacy leadership and management. Advocating for the appropriate and necessary resources to not only maintain a safe, accurate, and efficient drug use system while simultaneously advancing pharmacists’ role in direct patient care calls upon all these skills and abilities. This analysis begs further evaluation of how management and leadership skills are currently incorporated into the professional doctoral degree program and postgraduate education and training, including residencies. Pharmacy students are certainly required to develop team-oriented communication and problem-solving skills in today’s active learning approaches to professional pharmacy
Table 6. Descriptive Statistics for the Bottom 10 Rated SKAs in Delphi Round 2 SKA Item
Domain
Mean ± SDa
71. Ability to effectively use expert consultants
Pharmacy finance
5.24 ± 1.34
72. Knowledge of managed care cost terminology
Pharmacy finance
5.19 ± 1.12
73. Knowledge of statistical analysis
Total quality management of workflow systems
5.14 ± 1.20
74. Ability to effectively lobby lawmakers
Professional pharmacy leadership
5.00 ± 1.22
75. Ability to build relationships with colleges of pharmacy
Management and development of the pharmacy workforce
4.90 ± 1.26
76. Skills in developing clinical practice guidelines
Total quality management of workflow systems
4.90 ± 1.26
77. Skills in career management and planning
Management and development of the pharmacy workforce
4.76 ± 1.04
78. Skills in leading development of “city-wide” formularies
Total quality management of workflow systems
4.48 ± 1.72
79. Knowledge of the FDA’s drug approval process
Pharmacy finance
4.38 ± 1.24
80. Knowledge of ethical issues related to gene therapy
Pharmacy finance
4.10 ± 1.22
Abbreviation used: FDA, Food and Drug Administration; SD, standard deviation; SKA, skills, knowlege, and abilities. aRespondents
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rated items on a 7-point scale, ranging from 1, extremely unimportant, to 7, extremely important.
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61
RESEARCH
Pharmacy Executive Leadership Issues
education. More than one fourth of the curriculum is experiential, requiring team work with nonpharmacy personnel. Both didactic and experiential emphases are critical to building the next generation of effective pharmacy leadership. However, many would agree that in our efforts to provide graduates with the fundamentals of pharmacotherapy and thereby create clinicians equipped to deliver patient-focused, evidence-based care, sufficient emphasis on leadership and advanced management skills is lacking. Providing postgraduate opportunities to develop executive leadership skills is essential. Similarly, strong mentoring programs are vitally important. Future research could include the assessment of perceptions of emerging pharmacy leaders regarding the issues and the highly rated SKAs developed by the executives in this study. This would enable delineation of focus areas for the professional development of emerging leaders. Additionally, more detailed investigation of specific practice settings (i.e., institutional public versus mail service) may provide useful insights regarding the challenges that executives face across practice settings.
Limitations Limitations of this study include the low response rate and small sample size. While the response rate observed is considered sufficient based on comparable research, the input from more that one half of the sample of pharmacy executives was not captured. The degree of agreement among responders makes it unlikely that additional data provided by nonresponders would have dramatically altered the results. However, more responses would have been valuable and might have strengthened our findings. A larger sample size would also have been desirable and would have strengthened the power and generalizability of the results.
Conclusion Through successful integration of communication skills, critical thinking, and problem solving techniques, future public-sector pharmacy executives will be better equipped to effectively position their organizations and the profession for the challenges that lie ahead. Pharmacy executives who participated in this Delphi process rated highly several leadership abilities, including ability to see the big picture, demonstrate the value of pharmacy services, lead and manage in an ethical manner, and influence senior leaders in an organization. Combined with communications skills needed to convey pharmacy’s financial needs to senior managers, these capabilities should be the focus of postgraduate training and education activities for pharmacists seeking careers in pharmacy management in practice settings. Pharmacy certainly remains a patient-focused profession at all levels of service, whether pharmacist-clinician based practice or pharmacy management at the executive level. However, the means of supporting this effort may vary 62
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by practice setting. Pharmacy executives must advocate for appropriate and necessary resources to maintain a safe, accurate, and efficient drug use system and advance the pharmacist’s role in direct patient care.
References 1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–43. 2. O’Leary J, O’Leary P. What is the future for nurse executives? Nurs Adm Q. 1999;23:4–10. 3. Hudak RP, Brooke PP Jr., Finstuen K, Trounson J. Management competencies for medical practice executives: skills, knowledge and abilities required for the future. J Health Adm Educ. 1997;15:219–39. 4. William SJ. What skills do physician leaders need now and in the future? Physician Exec. 2001;27:46–8. 5. Meadows AB, Finstuen K, Hudak RP. Pharmacy executives: leadership issues and associated skills, knowledge, and abilities in the U.S. Department of Defense. J Am Pharm Assoc. 2003;43:412–8. 6. University of Pennsylvania Web site. GlaxoSmithKline executive management program for pharmacy leaders. Accessed at pharmacy leaders.net, November 30, 2004. 7. Helmer O. Analysis of the future: the Delphi method. Santa Monica, Calif.: RAND Corporation; 1967. Report P-3558. 8. Brown B, Cochran S, Dalkey N. The Delphi method II: structure of experiments. Santa Monica, Calif.: RAND Corporation; 1969. Report RM-5957PR. 9. Dalkey NC. The Delphi method: an experimental study of group opinion. Santa Monica, Calif.: RAND Corporation; 1969. Report RM-5888-PR. 10. Delbecq AL, Van de Ven AH, Gustafson DH. Group techniques for program planning: a guide to nominal group and Delphi processes. Glenview, Ill.: Scott Foresman; 1975. 11. American College of Healthcare Executives. Health care in the 1990s: trends and strategies. Ann Arbor, Mich.: Health Administration Press; 1984. 12. American College of Healthcare Executives. The future of healthcare: change and choice. Ann Arbor, Mich.: Health Administration Press; 1987. 13. American College of Healthcare Executives. The future of healthcare: physician and hospital relationships. Ann Arbor, Mich.: Health Administration Press; 1991. 14. Hudak RP, Brooke PP, Finstuen K. Forecast 2000: a prediction of skills, knowledge, and abilities required by senior medical treatment facility leaders into the 21st century. Mil Med. 1994;159:494–500. 15. Sentell JW, Finstuen K. Executive skills 21: a forecast of leadership skills and associated competencies required by naval hospital administrators into the 21st century. Mil Med. 1998;163:3–8. 16. Rogers JR, Finstuen K, Manglesdorff AD, Snyder GL. Executive competencies and skills required by United States Coast Guard health care administrators. AAMA Executive. 1998(winter):10–5. 17. Mangelsdorff AD, Rodgers JR, Zucker KW et al. Vision 21 Delphi Panel: Senior Army Medical Service Corps officers’ vision of behaviors for success of future Medical Service Corps officers. Mil Med. 1996;162:450–2. 18. Hudak RP, Brooke PP, Finstuen K, Riley P. Health care administration in the year 2000: practitioners’ views of future issues and job requirements. Hosp Health Serv Adm. 1993;38:181–95. 19. Brooke PP, Hudak RP, Finstuen K, Trounson J. Management competencies required in ambulatory care settings. Physician Exec. 1998;24:32–8. 20. Wineman JA, Mangelsdorff AD, Finstuen K. Senior executive behaviors for the Army dental care system of the 21st century. Mil Med. 1998;163:377–80. 21. Peters AD, Dominguez DG, Finstuen K. Vision 2005: a forecast of executive leadership skills and associated competencies required by Navy Dental Corps officers into the 20th century. Navy Med. 2000;92:10–5. 22. Nunnally JC. Psychometric theory, 2nd ed. New York: McGraw-Hill; 1978. 23. Hudak RP, Brooke PP, Finstuen K. Identifying management competencies for health care executives: review of a series of Delphi studies. J Health Adm Educ. 2000;18:213–43.
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