- Email: [email protected]
Sustainability of pharmacy-based innovations: The case of in-house immunization services
Research
Sustainability of pharmacybased innovations: The case of in-house immunization services Salisa C. Westrick and Michelle L. Breland
Received May 14, 2008, and in revised form September 23, 2008. Accepted for publication November 7, 2008.
Abstract Objective: To examine the effect of organization-level factors on sustainability of pharmacy-based in-house immunization services. Design: Cross-sectional study. Setting: Washington State community pharmacies in 2006. Participants: Key informants of 490 community pharmacies. Intervention: Mixed-mode survey; five mail and telephone contacts were used. Main outcome measures: Effectiveness of champions (i.e., influential individuals within the host organization who actively and continuously promote the service), formal evaluation process, degree of modifications made to in-house services, degree of compatibility between in-house services and the host pharmacy, and sustainability of in-house immunization services were measured and included in the proposed model. Using survey responses, factor analysis and path analysis were performed to determine the relationships among these variables. Results: Of the 490 survey instruments sent, 1 was undeliverable, 2 were incomplete, and 206 were completed (42.1% response rate). A total of 104 pharmacies that reported offering immunization services in 2006 were included in the analysis. Compatibility, which was defined as the fit between in-house immunization services and the host pharmacy, was the key to sustainability of immunization services. To enhance compatibility between in-house services and the host pharmacy, two pathways were found. First, in-house services underwent formal evaluations and subsequent modifications were made to the services. The second pathway bypassed the adaptation process. Through the second pathway, an operational champion implemented in-house services in a way that was already compatible with the host pharmacy. Conclusion: Organizational leaders and practitioners had the potential to sustain in-house services. The key factors included in the model should be incorporated as an integral part of programs planning to foster sustainability of in-house immunization services. Keywords: Immunizations, health care delivery, pharmacy services, sustainability, innovation, adoption, abandonment, community pharmacy. J Am Pharm Assoc. 2009;49:500–508. doi: 10.1331/JAPhA.2009.08055
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Salisa C. Westrick, PhD, is Assistant Professor, and Michelle L. Breland, MEd, is a doctoral student, Pharmacy Care Systems, Harrison School of Pharmacy, Auburn University, Auburn, AL. Correspondence: Salisa C. Westrick, 207 Dunstan Hall, Pharmacy Care Systems, Auburn, AL 36849. Fax: 334-844-8307. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Washington State pharmacists who participated in this study and to Dr. Jeanine Mount and Suntaree Watcharadamrongkun for helpful comments. Funding: Supported by the American Association of Colleges of Pharmacy New Investigator Grant Program. Previous presentation: A preliminary version of this article was presented at the American Pharmacists Association Annual Meeting, San Diego, CA, March 14–17, 2008.
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Sustainability of in-house immunization services Research
T
o optimize patient outcomes, the practice of pharmacy needs to shift its focus from traditional dispensing to patient care services. Because community pharmacies spend considerable resources in developing and implementing patient care services,1 a planned approach that involves formulating objectives and actionable strategies to foster long-term sustainability of effective services should be used.2 Because little information is available to guide pharmacy leaders in developing effective plans to improve sustainability,3 the goal of this study was to gain a better understanding of factors affecting sustainability of innovative services in community pharmacies. An in-house immunization service was selected as an innovative service to be studied. In-house immunization service is defined as staff pharmacists administering vaccines at their practice site.4,5 In the previous decade, extensive efforts were made to promote in-house immunization services to help address public health problems, as indicated in Healthy People 2010.4,6,7 As a result of these efforts, pharmacist/pharmacy involvement in in-house immunization services increased from 3.1% (1998) to 8.1% (2001) to 13.7% (2004).8–10 Although the increased involvement is worth celebrating, one-third of pharmacies that began in-house immunization services had discontinued or planned to discontinue the service.10 Therefore, this
At a Glance
Synopsis: Key informants of 490 community pharmacies in Washington State were surveyed to evaluate the effect of organization-level factors on sustainability of pharmacy-based in-house immunization services. Compatibility—the fit between in-house immunization services and the host pharmacy—was found to be the key to sustaining immunization services. Two pathways to enhancing compatibility between in-house services and the host pharmacy were found: (1) formal evaluation and subsequent modification of the services and (2) implementation of in-house services by an operational champion in a manner already compatible with the host pharmacy. Analysis: The proposed model and observations in the current study may be applicable to other pharmacy services (e.g., medication therapy management services, tobacco-cessation programs), and organizational leaders and practitioners are encouraged to consider the key factors in the study model and incorporate them as an integral part of program planning and implementation. Researchers who seek to sustain interventions beyond the intervention period may also benefit from this work. If an intervention appears compatible with the current operations of a pharmacy, the intervention likely will be sustainable. If, however, the intervention does not seem compatible, researchers must ensure that formal evaluations are conducted and modifications to the intervention can be made to enhance the sustainability of the intervention.
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study explored reasons for sustainability of in-house immunization services. The study model of sustainability of in-house immunization services consists of five key variables that were drawn from a previous work describing a program sustainability framework and organized by using the structure–process–output framework (Figure 1).2,11 First, champions are influential individuals within the host organization who actively and continuously promote the service.2,12–14 Strong evidence of the effect of champions on increasing the sustainability were found.2,15–17 Second, a formal program evaluation allows an organization to continuously monitor how the service meets the set objectives.18,19 Information obtained from the evaluations is used to inform the organizational leaders regarding necessary modifications. Next, modification is the extent to which the innovation is modified during an adaptation process.20 Research found that services that were modifiable were more likely to be sustained.1,2,19,21,22 Fourth, compatibility is defined as the extent to which in-house services fit within the host pharmacy in terms of staff pharmacists’ skills, physical resources, workflow, and organization mission. Several studies found that compatibility is necessary to increase sustainability of the service.15,22–24 Lastly, sustainability is defined as the attainment of long-term viability and integration of in-house immunization services within an organization.13 By definition, sustainability is not simply service continuation; it addresses the extent to which a service becomes integrated in the host organization.15,25,26 Synonyms for sustainability are routinization and institutionalization.2,27 The study model is organized by using the structure–process–output framework.11 Structure refers to the properties of the organization in which the in-house services are provided. Process is the adaptation process by which in-house services are formally evaluated and modified to fit within the host organization. Outputs are the results of implementing the in-house services and are classified as intermediary (the level of compatibility) and ultimate (sustainability of in-house services) outputs.
Objectives The goal of this study was to increase understanding of factors affecting sustainability of pharmacy-based patient care services. To accomplish this goal, in-house immunization services were used as an example of innovative patient care services provided by community pharmacies. The specific objective of this study was to explore the relationships among effectiveness of champions, formal evaluation, degree of modifications made to in-house services, degree of compatibility between in-house services and the host pharmacy, and sustainability of in-house immunization services, as identified in the proposed model (Figure 1).
Methods Study design and data collection
Data presented in this study were collected during stage 3 of a multistage study of pharmacy-based immunization serwww.japha.org
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Structure
Process
Output Intermediary output
Ultimate output
Formal evaluation Champion effectiveness
Modifications made to inhouse services
Compatibility between inhouse services and host pharmacy
Sustainability of in-house immunization services
Figure 1. Study model of sustainability of in-house immunization services vices in Washington State community pharmacies. The overall goal of the multistage study was to better understand the trend of pharmacy-based immunization services and to identify factors influencing the adoption and sustainability of immunization services. The unit of analysis was at the pharmacy level, and information was gathered from key informants of community pharmacies in three stages in 2003, 2004, and 2006–2007. Key informants of community pharmacies included pharmacy managers or pharmacists on duty who were able to answer questions related to immunization activities in their pharmacies. Study procedures and use of data received exempt status from review by the institutional review board of the authors’ institution. Data presented in this report were obtained from the stage 3 survey conducted in 2006–2007. Because stage 1 survey respondents served as potential stage 3 respondents, describing how stage 1 and stage 3 surveys were conducted is imperative. For the stage 1 survey, a postcard-size mail survey instrument was sent to all Washington State community pharmacies in 2003. Of the 1,143 survey instruments sent, 2 were undeliverable, 13 involved incomplete responses, and 315 were completed (27.6% response rate). Follow-up telephone calls were made with 262 randomly selected pharmacies that did not respond to the mail survey. Of the 262 pharmacies, phone numbers were incorrect for 21 and the telephone interview was completed for 211 (87.6% response rate). Thus, a total of 526 stage 1 participating pharmacies were obtained using a combination of mail and telephone surveys. Regarding stage 1 nonresponse bias, a greater proportion of pharmacies in the mail survey compared with the telephone survey reported being involved in in-house immunization services.28 This could be a result of in-house immunization service providers realizing the importance of the pharmacy-based immunizations topic29–33 and therefore were more likely to respond to the stage 1 survey promptly. From December 2006 to February 2007, a modified Dill502 • JAPhA • 4 9 : 4 • J u l / A u g 2009
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man method34,35 with a telephone reminder was used to conduct a stage 3 mail survey with stage 1 respondents. Of the 526 stage 1 responding pharmacies, a total of 36 pharmacies were excluded from stage 3 because of a change in physical address and/or ownership. This stage 3 survey consisted of five contacts: a prenotification postcard, a survey instrument packet, a thank you/reminder postcard, a reminder telephone call, and a replacement survey instrument packet. Mail contacts were sent via first-class mail. For pharmacies not responding to the survey after receiving the reminder postcard, reminder telephone calls were made with a limit of four call attempts per pharmacy. Study variables and measures
In the self-administered survey instrument, key informants were asked to identify whether their pharmacy offered in-house immunization services in 2006. If they did offer the services, key informants would then answer questions related to championing of in-house services, how in-house services were evaluated, the extent of modifications made to in-house services, level of compatibility between in-house services and their pharmacy, and level of sustainability of in-house immunization services. Questions used to measure these variables can be found in Appendix 1 (electronic version of this article, available online at www.japha.org). For example, for formal evaluation, key informants were asked how their in-house immunization services were evaluated. If they responded “yes” to either formal evaluation conducted by employees who were involved in providing services or formal evaluation conducted by management, their responses were coded as 1 (i.e., formal evaluation was conducted). The sustainability scale, consisting of six items, was modified from Goodman et al.25 Key informants were asked to rate degree of agreement with six items on a 5-point Likert-type scale (“strongly disagree” [–2] to “strongly agree” [2]); sustainability was the mean score of the six items. Journal of the American Pharmacists Association
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Principal-component analyses with varimax rotation based on eigenvalues greater than 1 were conducted to ensure that each scale had one underlying component. All study constructs, except formal evaluation, were assessed for internal consistency reliability using Cronbach’s alpha coefficient. Scales exhibiting alpha values greater than 0.70 were considered reliable.36 Data analysis
Data were analyzed using SPSS version 16.0 (SPSS, Chicago). Because this study investigated factors influencing the extent of sustainability of in-house immunization services (i.e., the extent to which pharmacies attain long-term viability and integrate in-house immunization services within the normal operations of their organizations), pharmacies had to provide in-house immunization services in 2006 to be included in the study. If a pharmacy discontinued its in-house services before 2006, it was not included. Descriptive statistics were used to describe characteristics of respondents. Further, proposed relationships in the study model were explored using linear regression analyses to assess both direct and indirect effects of variables in the study model. Because insignificant differences often exist between the results of logistic regression and linear regression when the dependent variable is a dichotomous variable,37 we simplified how results were presented in the study model by reporting results of a linear regression when formal evaluation was used as the dependent variable. The variance inflation factor (VIF) was calculated for each independent variable. VIF is a measure used to indicate the degree of collinearity of an independent variable with the other independent variables in the model. All statistical analyses were based on a significance level of 0.05. Nonresponse bias investigation
To assess nonresponse bias for the stage 3 survey, characteristics of stage 3 nonrespondents and survey respondents were compared. To collect nonrespondent data, telephone calls were made with 68 randomly selected pharmacies using a structured telephone script with an abridged version of the stage 3 mail survey instrument. The abridged telephone survey instrument collected information from key informants regarding their demographic information, pharmacy’s characteristics, and in-house service adoption status. Nonresponse telephone surveys were made with a limit of four call attempts per pharmacy. Analysis of variance and Pearson chi-square tests were used when respondents’ characteristics were continuous and categorical variables, respectively.
Results Stage 3 response rate, respondent characteristics, and nonresponse bias
Of 490 survey instruments sent, 1 was undeliverable, 2 were considered incomplete, and 206 were completed (response rate 42.1%). Table 1 describes characteristics of Journal of the American Pharmacists Association
stage 3 respondents. The majority of key informants were male (64.0%), held a BPharm degree (79.5%), were pharmacy managers (71.0%), and had completed immunization training (62.4%). Many participating pharmacies were independently owned (34.9%) or part of chain or mass merchandisers (41.9%). About two-thirds of participating pharmacies had one to two full-time equivalent pharmacists (66.9%), and about three-quarters reported an average daily prescription volume of fewer than 250 (75.3%). A total of 104 (54.2%) were in-house service providers in 2006. These 104 pharmacies were included in the regression analyses. Table 1 also describes characteristics of these 104 in-house service providers. For stage 3 nonresponse bias investigation, of the 68 randomly selected pharmacies that did not respond to the stage 3 mail survey, 7 pharmacies did not provide direct pharmacy services to the public and 3 had disconnected telephone numbers. Hence, of the 58 eligible pharmacies, 38 completed the telephone interview (response rate 65.5%). When characteristics of stage 3 respondents were compared with those who did not respond, the results revealed statistically significant differences in three variables (online Appendix 2). Specifically, among respondents, a greater proportion of key informants had a BPharm degree (χ2 = 4.799, df = 1; P < 0.05), held the owner/partner job position (χ2 = 6.322, df = 2; P < 0.05), and completed an immunization certification program (χ2 = 4.076, df = 1; P < 0.05). However, no statistically significant differences existed for the other eight variables. Descriptive statistics and reliability of constructs
Principal component analyses showed that each scale had one underlying component. The champion effectiveness scale, adapted from Hays et al.,38 was an exception; rather than loading on a single component, items in this scale loaded on two components. As a result, the decision was made to separate the eight items into two champion effectiveness subscales (online Appendix 1). The first subscale focused on broader leadership roles that supported in-house immunization services. It included questions related to the champion’s commitment to the pharmacy’s mission, ability to garner resources, ability to obtain collaboration from a physician, and advocating for the continuation of immunization services. The second subscale, on the other hand, focused on ability of champions to manage in-house immunization services and handle problems, if any arise. It included four items asking respondents to describe the person in charge of immunization services in terms of their leadership and guidance in the maintenance of in-house services, knowledge about immunization services, ability to manage conflict, and ability to solve problems and issues at the practice site. The first and second subscales are referred to as strategic champion effectiveness and operational champion effectiveness, respectively. A summary of the constructs, number of items per construct, reliability, mean (±SD), and scale range was www.japha.org
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Table 1. Characteristics of stage 3 respondents (n = 206) and respondents included in the analysis (n = 104) Variable Sex Male Female Pharmacy degree BPharm PharmD Job position Staff pharmacist Manager Owner/partner Completed immunization training No Yes Pharmacy ownership Single/multistore independently owned Chain/mass merchandiser Grocery/supermarket Clinic Pharmacists employed 1 FTE 1.1–2.0 FTEs >2.0 FTEs PharmD pharmacists employed None 0.1–1.0 FTE >1 FTE No. staff pharmacists trained in immunizations None One Two Three or more No. staff pharmacists who actively administer vaccines None One Two Three or more Average prescription volume per day 1–150 151–250 ≥251 Provider of in-house services No Yes Abbreviation used: FTE, full-time equivalent. a Totals may vary due to missing data. reported in Table 2. Reliability analysis for each scale revealed acceptable reliability. Reliability coefficient of strategic champion effectiveness was the lowest (0.71); nonetheless, it was considered acceptable.36 Unlike other vari504 • JAPhA • 4 9 : 4 • J u l / A u g 2009
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Stage 3 respondents No. (%)a
Respondents included in the path analysis No. (%)a
126 (64.0) 71 (36.0)
65 (64.0) 35 (36.0)
159 (79.5) 41 (20.5)
74 (73.3) 27 (26.7)
17 (9.3) 130 (71.0) 36 (19.7)
13 (14.1) 67 (72.8) 12 (13.0)
68 (37.6) 113 (62.4)
11 (12.4) 78 (87.6)
65 (34.9) 78 (41.9) 30 (16.1) 13 (7.0)
27 (28.7) 46 (48.9) 20 (21.3) 1 (1.1)
49 (24.3) 86 (42.6) 67 (33.2)
22 (21.8) 32 (31.7) 47 (46.5)
87 (52.1) 50 (29.9) 30 (18.0)
35 (40.2) 31 (35.6) 21 (24.1)
62 (30.7) 69 (34.2) 45 (22.3) 26 (12.9)
0 44 (42.3) 34 (32.7) 26 (25.0)
92 (45.8) 56 (27.9) 32 (15.9) 21 (10.4)
0 54 (51.9) 29 (27.9) 21 (20.2)
68 (35.1) 78 (40.2) 48 (24.7)
29 (29.6) 36 (36.7) 33 (33.7)
88 (45.8) 104 (54.2)
0 104 (100.0)
ables included in the study model, formal evaluation was a dichotomous variable (1, a pharmacy formally evaluated in-house services; 0, a pharmacy did not formally evaluate in-house services). More than one-half of pharmacies Journal of the American Pharmacists Association
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Table 2. Descriptive statistics and reliability of constructs (n = 104) Construct Items Reliabilitya Mean ± SD Possible scale range b 4 0.71 4.66 ± 0.50 1–5 Strategic champion effectiveness Operational champion effectivenessb 4 0.81 4.57 ± 0.54 1–5 Modifications made to in-house servicesb 5 0.84 2.77 ± 1.01 1–5 Compatibility between in-house services and the host pharmacyc 4 0.85 3.26 ± 0.96 1–5 Sustainability of in-house servicesd 6 0.83 0.76 ± 0.66 –2 to 2 a Cronbach’s coefficient alpha. b Each item measured by 1, not at all; 2, a little; 3, to some extent; 4, to a moderate extent; 5, to a great extent. c Each item measured by 1, very poor fit; 2, poor fit; 3, moderate fit; 4, good fit; 5, very good fit. d Each item measured by –2, strongly disagree; –1, disagree; 0, neither agree nor disagree; 1, agree; 2, strongly agree.
Table 3. Linear regression analyses in the proposed sustainability model (n = 104) Standardized coefficient Dependent variable: formal evaluation Strategic champion effectiveness Operational champion effectiveness Dependent variable: degree of modifications made to in-house services Strategic champion effectiveness Operational champion effectiveness Formal evaluation Dependent variable: degree of compatibility between in-house service and the host pharmacy Strategic champion effectiveness Operational champion effectiveness Formal evaluation Modifications Dependent variable: degree of sustainability of in-house immunization services Strategic champion effectiveness Operational champion effectiveness Formal evaluation Modifications Compatibility (51.6%) reported having a formal evaluation process in place. Relationships of key variables in the proposed study model
Of the 206 respondents, a total of 104 pharmacies that provided in-house immunization services in 2006 were included in the analyses. Figure 2 and Table 3 show results of linear regression analyses for the proposed sustainability model. In the analysis, when sustainability was used as the dependent variable, VIF for the independent variables ranged from 1.22 to 1.54, indicating that multicollinearity was not a problem. The regression model indicates that 42% of the variance in sustainability can be predicted from strategic champion effectiveness, operational champion effectiveness, whether a formal evaluation was conducted, degree of modifications made to inhouse services, and degree of compatibility (Table 3). Compatibility between in-house services and the host pharmacy was the only significant predictor of sustainability of in-house serJournal of the American Pharmacists Association
P
0.26 –0.11
0.038 0.362
0.05 0.05 0.31
0.705 0.698 0.005
0.12 0.31 0.20 0.26
0.300 0.005 0.049 0.009
0.00 0.09 0.19 0.16 0.45
0.978 0.419 0.050 0.091 0
R2 0.05
0.11
0.32
0.42
vices (P < 0.05). The path coefficient (0.45) indicates that for every unit increase in the degree of compatibility, the degree of sustainability of in-house services was increased by 0.45 units. Using compatibility as the dependent variable, the model reveals that 32% of the variance in compatibility can be explained from strategic and operational champion effectiveness, formal evaluation, and modifications made to in-house services. Further, the statistically significant path coefficients using compatibility as the dependent variable were 0.31 for operational champion effectiveness, 0.20 for formal evaluation, and 0.26 for degree of modifications made to in-house services. With modifications made to in-house services as the dependent variable, the model shows that 11% of the variance in degree of modifications can be explained using strategic and operational champion effectiveness and whether a formal evaluation process was used. The only statistically significant path coefficient was 0.31 for formal evaluation. In the analysis, when formal evaluation was used as the dependent variable, strategic champion effectiveness was a sigwww.japha.org
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0.00 0.12
Strategic champion effectiveness
0.26a
Formal evaluation
0.20a
–0.11 r = 0.50b Operational champion effectiveness
0.31b 0.05 0.05
Modifications made to inhouse services
0.26b
0.19 Compatibility between inhouse services and host pharmacy
0.45b 0.16
Sustainability of in-house immunization services
0.31b 0.09
Figure 2. Standardized path coefficients for sustainability of in-house immunization services model a P < 0.05. b P < 0.01. nificant predictor, with the statistically significant path coefficient of 0.26. The result was confirmed with a logistic regression. No differences in the conclusion between the linear and logistic regression analyses were found. With each additional unit increased in strategic champion effectiveness, the odds of using a formal process to evaluate in-house services (versus not having a formal process) increased by a factor of 3.36, controlling for operational champion effectiveness.
Discussion This study examined factors facilitating sustainability of pharmacy-based patient care services. Drawing from the program sustainability framework2 and the structure–process–output framework,11 the proposed model conceptualizes how a pharmacy can sustain in-house immunization services. Sustainability, in this study, is defined as the attainment of long-term viability and integration of in-house immunization services within the normal operations of an organization.13,15,25 Results revealed that compatibility was a predictor of the sustainability of in-house immunization services. This is consistent with other studies that suggested compatibility between the innovation and the host organization is necessary.13,15,22,24 That is, if in-house immunization services fit well with the pharmacy’s mission, objectives, and routines, they are likely to remain viable. Results further suggest that to achieve the desired level of compatibility, two pathways can be followed. The first pathway emphasizes the importance of in-house immunization services undergoing an adaptation stage to enhance compatibility between in-house services and the host pharmacy. The adaptation stage involves two components: a formal evaluation and modification process. After in-house immunization services are implemented, formal evaluations are conducted. Informa506 • JAPhA • 4 9 : 4 • J u l / A u g 2009
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tion obtained from the evaluations is then used to recommend to the organizational leaders whether any modifications need to be made to the in-house services. Conducting formal evaluations and making modifications to in-house immunization services will result in a greater degree of compatibility between the host pharmacy and in-house services. We recommend conducting formal evaluations regularly because an innovation must be adapted to new needs and circumstances if it is to continue.16 Generally, in this pathway, a strategic champion who possesses a general supportive leadership role has a considerable effect on implementing a formal evaluation. Unlike the first pathway, in-house immunization services do not go through the adaptation process. That is, with the second pathway, a host pharmacy implements in-house immunization services in a way that is compatible with the current workflow, staff skills, pharmacy resources, and pharmacy mission. Generally, a pharmacy that follows this pathway has an operational champion who possesses knowledge about inhouse immunization services and has an ability to handle problematic issues, if any arise. Given the knowledge related to inhouse services and ability to manage and handle problematic issues, the champion can decide how in-house services should be scheduled (e.g., walk-in versus appointment, year-round versus seasonal), what type of vaccines should be offered, how many employees should be involved, and how space/privacy area should be used. Operational knowledge is found to be helpful in selecting a compatible format of in-house immunization services without the need for any modifications. The second pathway can be used as a substitute for or as a complement to the adaptation process but perhaps is not essential. Although this research study has focused on in-house immunization services, the proposed model and findings may be applicable to other pharmacy-based innovative practices such Journal of the American Pharmacists Association
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as medication therapy management services and tobacco-cessation programs. We recommend that organizational leaders and practitioners consider the key factors in the study model and incorporate them as an integral part of the program planning and implementation processes. Doing this may foster sustainability of innovative services. This study may also benefit researchers who seek to sustain interventions beyond the intervention period. Our findings offer an explanation that incompatibility between the intervention and the host pharmacy may be a reason why some innovative services were not sustained.39,40 Researchers should have sustainability as a consciously planned goal rather than a latent goal. To foster sustainability, the researchers must determine how best to enhance the compatibility between the intervention and the host pharmacy. If the intervention seems to be compatible with the current pharmacy operations, the intervention likely will be sustainable. If, however, the intervention does not seem compatible, the researchers must ensure that formal evaluations are conducted and modifications to the intervention can be made to enhance the sustainability of the intervention. Because making changes to the intervention during the intervention period may jeopardize the validity of the intervention study, we recommend implementing a modifications plan immediately after the intervention period. Finally, ceiling effects were observed in both strategic and operational champion effectiveness subscales (mean 4.66 and 4.57, respectively). Despite the low variability in responses for these two subscales, we still found a significant relationship between strategic champion effectiveness and formal evaluation and between operational champion effectiveness and compatibility. We recommend that future researchers refine these subscales by reducing the ceiling effect and reexamine the effects of champion effectiveness on sustainability of in-house immunization services.
Limitations The first limitation of the current study was related to the use of key informants as a source of information, as they were subject to recall errors and may have limited knowledge of the survey topics. Second, because of the cross-sectional nature of the study design, causal inferences should be made with caution. Next, this study investigated the effects of only particular factors; all factors possibly influencing sustainability were not evaluated. Further, this study did not include pharmacies that already abandoned in-house services; therefore, it did not identify factors related to the abandonment of in-house services. Future research should include an investigation of reasons for service discontinuation as its priority area. Finally, the study may have limited generalizability to the nonrespondents in Washington State, to states other than Washington, and to other innovations.
Conclusion This study investigated factors fostering sustainability of in-house immunization services in community pharmacies. Organizational leaders and practitioners had the potential to Journal of the American Pharmacists Association
sustain in-house services by enhancing compatibility between in-house services and the host pharmacy. Conducting formal evaluations and making modifications to in-house immunizations services will result in a greater degree of compatibility between the host pharmacy and in-house services. Knowledge of in-house immunization services and operations also was found to be helpful in selecting in-house immunization services that are compatible with the host pharmacy. This knowledge can be used as a substitute for or as a complement to the adaptation process but perhaps is not essential. Organizational leaders, researchers, and practitioners should incorporate these key factors as an integral part of the program planning in order to enhance sustainability of innovative services. References 1. Goodman RM, Steckler AB. The life and death of a health promotion program: an institutionalization case study. Int Q Community Health Educ. 1987-1988;8(1):5–21. 2. Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice, and policy. Health Educ Res. 1998;13:87–108. 3. Greenhalgh T, Robert G, Bate P, et al. Diffusion of innovations in health service organizations: a systematic literature review. Malden, MA: Blackwell; 2005. 4. Grabenstein JD. Pharmacists as vaccine advocates: roles in community pharmacies, nursing homes, and hospitals. Vaccine. 1998;16:1705–10. 5. Savino LB. Your pharmacy and immunizations. Americas Pharmacist. 1998;120(7):49–53. 6. Department of Health and Human Services. Healthy People 2010: understanding and improving health and objectives for improving health. Vol. 2. Washington, DC: U.S. Government Printing Office; 2000. 7. Steyer TE, Ragucci KR, Pearson WS, Mainous AG. The role of pharmacists in the delivery of influenza vaccinations. Vaccine. 2004;22:1001–6. 8. Madhavan SS, Rosenbluth SA, Amonkar M, et al. Pharmacists and immunizations: a national survey. J Am Pharm Assoc. 2001;41:32–45. 9. Kamal KM, Madhavan SS, Maine LL. Pharmacy and immunization services: pharmacists’ participation and impact. J Am Pharm Assoc. 2003;43:470–87. 10. Westrick SC, Mount JK, Watcharadamrongkun S, Breland ML. Pharmacy stages of involvement in pharmacy-based immunization services: results from a 17-state survey. J Am Pharm Assoc. 2008;48:764–73. 11. Donabedian A. Explorations in quality assessment and monitoring: the definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press; 1980. 12. Howell JM, Higgins CA. Champions of technological innovation. Adm Sci Q. 1990;35:317–41. 13. Steckler AB, Goodman RM. How to institutionalize health promotion programs. Am J Health Promot. 1989;3(4):34–44. 14. Achilladelis B, Jervis P, Robertson A. A study of success and failure in industrial innovation. Sussex, U.K.: University of Sussex Press; 1971. www.japha.org
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16. Scheirer MA. Is sustainability possible? A review and commentary on empirical studies of program sustainability. Am J Eval. 2005;26:320–47.
29. Groves RM, Presser S, Dipko S. The role of topic interest in survey participation decisions. Public Opin Q. 2004;68(1):2–31.
17. Scheirer MA. The life cycle of an innovation: adoption versus discontinuation of the fluoride mouth rinse program in schools. J Health Soc Behav. 1990;31:203–15. 18. Johnson K, Hays C, Center H, Daley C. Building capacity and sustainable prevention innovations: a sustainability planning model. Eval Program Plann. 2004;27:135–49. 19. Glaser EM. Durability of innovations in human service organizations: a case study analysis. Knowledge: Creation, Diffusion, Utilization. 1981;3:167–85. 20. Rogers EM. Diffusion of innovation. 5th ed. New York: Free Press; 2003. 21. Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health. 2003;26:177–93. 22. O’Loughlin J, Renaud L, Richard L, et al. Correlates of the sustainability of community-based heart health promotion interventions. Prev Med. 1998;27:702–12. 23. Steckler A, Goodman RM. How to institutionalize health promotion programs. Am J Health Promot. 1989;3(4):34–44. 24. Gladwin K, Dixon RA, Wilson TD. Rejection of an innovation: health information management training materials in east Africa. Health Policy Plan. 2002;17:354–61. 25. Goodman RM, McLeroy KR, Steckler AB, Hoyle RH. Development of level of institutionalization scales for health promotion programs. Health Educ Q. 1993;20:161–78. 26. Goodman RM, Steckler AB. A framework for assessing program institutionalization. International Journal of Knowledge Transfer. 1989;2(1):57–71. 27. Yin RK. Changing urban bureaucracies: how new practices become routinized. Lexington, MA: Lexington Books; 1979.
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30. Smith FJ, Weidner D. Threatening and violent incidents in community pharmacies: an investigation of the frequency of serious and minor accidents. Int J Pharm Pract. 1996;4:136–44. 31. Solberg LI, Plane MB, Brown RL, et al. Non-response bias: does it affect measurement of clinician behavior. Med Care. 2002;40:347–52. 32. Fowler FJ, Gallagher PM, Stringfellow VL, et al. Using telephone interviews to reduce nonresponse bias to mail surveys of health plan members. Med Care. 2002;40:190–200. 33. Westrick SC, Mount JK. Effects of repeated callbacks on response rate and nonresponse bias: results from a 17-state pharmacy survey. Res Social Adm Pharm. 2008;4:46–58. 34. Dillman DA. Mail and internet surveys: the tailored design method. 2nd ed. New York: Wiley & Sons; 1999. 35. Dillman DA. Design and administration of mail surveys. Annu Rev Sociol. 1991;17:225–49. 36. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw-Hill; 1994. 37. Cleary PD, Angel R. The analysis of relationships involving dichotomous dependent variables. J Health Soc Behav. 1984;25:334–48. 38. Hays CE, Hays SP, DeVille JO, Mulhall PF. Capacity for effectiveness: the relationship between coalition structure and community impact. Eval Program Plann. 2000;23:373–9. 39. Farris KB, Schopflocher DP. Between intention and behavior: an application of community pharmacists’ assessment of pharmaceutical care. Soc Sci Med. 1999;49:55–66. 40. Odedina FI, Segal R, Hepler CD, et al. Changing pharmacists’ practice pattern: pharmacists’ implementation of pharmaceutical care factors. J Soc Adm Pharm. 1996;13(2):74–88.
Journal of the American Pharmacists Association
Sustainability of pharmacybased innovations: The case of in-house immunization services Salisa C. Westrick and Michelle L. Breland
Received May 14, 2008, and in revised form September 23, 2008. Accepted for publication November 7, 2008.
Abstract Objective: To examine the effect of organization-level factors on sustainability of pharmacy-based in-house immunization services. Design: Cross-sectional study. Setting: Washington State community pharmacies in 2006. Participants: Key informants of 490 community pharmacies. Intervention: Mixed-mode survey; five mail and telephone contacts were used. Main outcome measures: Effectiveness of champions (i.e., influential individuals within the host organization who actively and continuously promote the service), formal evaluation process, degree of modifications made to in-house services, degree of compatibility between in-house services and the host pharmacy, and sustainability of in-house immunization services were measured and included in the proposed model. Using survey responses, factor analysis and path analysis were performed to determine the relationships among these variables. Results: Of the 490 survey instruments sent, 1 was undeliverable, 2 were incomplete, and 206 were completed (42.1% response rate). A total of 104 pharmacies that reported offering immunization services in 2006 were included in the analysis. Compatibility, which was defined as the fit between in-house immunization services and the host pharmacy, was the key to sustainability of immunization services. To enhance compatibility between in-house services and the host pharmacy, two pathways were found. First, in-house services underwent formal evaluations and subsequent modifications were made to the services. The second pathway bypassed the adaptation process. Through the second pathway, an operational champion implemented in-house services in a way that was already compatible with the host pharmacy. Conclusion: Organizational leaders and practitioners had the potential to sustain in-house services. The key factors included in the model should be incorporated as an integral part of programs planning to foster sustainability of in-house immunization services. Keywords: Immunizations, health care delivery, pharmacy services, sustainability, innovation, adoption, abandonment, community pharmacy. J Am Pharm Assoc. 2009;49:500–508. doi: 10.1331/JAPhA.2009.08055
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Salisa C. Westrick, PhD, is Assistant Professor, and Michelle L. Breland, MEd, is a doctoral student, Pharmacy Care Systems, Harrison School of Pharmacy, Auburn University, Auburn, AL. Correspondence: Salisa C. Westrick, 207 Dunstan Hall, Pharmacy Care Systems, Auburn, AL 36849. Fax: 334-844-8307. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Washington State pharmacists who participated in this study and to Dr. Jeanine Mount and Suntaree Watcharadamrongkun for helpful comments. Funding: Supported by the American Association of Colleges of Pharmacy New Investigator Grant Program. Previous presentation: A preliminary version of this article was presented at the American Pharmacists Association Annual Meeting, San Diego, CA, March 14–17, 2008.
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T
o optimize patient outcomes, the practice of pharmacy needs to shift its focus from traditional dispensing to patient care services. Because community pharmacies spend considerable resources in developing and implementing patient care services,1 a planned approach that involves formulating objectives and actionable strategies to foster long-term sustainability of effective services should be used.2 Because little information is available to guide pharmacy leaders in developing effective plans to improve sustainability,3 the goal of this study was to gain a better understanding of factors affecting sustainability of innovative services in community pharmacies. An in-house immunization service was selected as an innovative service to be studied. In-house immunization service is defined as staff pharmacists administering vaccines at their practice site.4,5 In the previous decade, extensive efforts were made to promote in-house immunization services to help address public health problems, as indicated in Healthy People 2010.4,6,7 As a result of these efforts, pharmacist/pharmacy involvement in in-house immunization services increased from 3.1% (1998) to 8.1% (2001) to 13.7% (2004).8–10 Although the increased involvement is worth celebrating, one-third of pharmacies that began in-house immunization services had discontinued or planned to discontinue the service.10 Therefore, this
At a Glance
Synopsis: Key informants of 490 community pharmacies in Washington State were surveyed to evaluate the effect of organization-level factors on sustainability of pharmacy-based in-house immunization services. Compatibility—the fit between in-house immunization services and the host pharmacy—was found to be the key to sustaining immunization services. Two pathways to enhancing compatibility between in-house services and the host pharmacy were found: (1) formal evaluation and subsequent modification of the services and (2) implementation of in-house services by an operational champion in a manner already compatible with the host pharmacy. Analysis: The proposed model and observations in the current study may be applicable to other pharmacy services (e.g., medication therapy management services, tobacco-cessation programs), and organizational leaders and practitioners are encouraged to consider the key factors in the study model and incorporate them as an integral part of program planning and implementation. Researchers who seek to sustain interventions beyond the intervention period may also benefit from this work. If an intervention appears compatible with the current operations of a pharmacy, the intervention likely will be sustainable. If, however, the intervention does not seem compatible, researchers must ensure that formal evaluations are conducted and modifications to the intervention can be made to enhance the sustainability of the intervention.
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study explored reasons for sustainability of in-house immunization services. The study model of sustainability of in-house immunization services consists of five key variables that were drawn from a previous work describing a program sustainability framework and organized by using the structure–process–output framework (Figure 1).2,11 First, champions are influential individuals within the host organization who actively and continuously promote the service.2,12–14 Strong evidence of the effect of champions on increasing the sustainability were found.2,15–17 Second, a formal program evaluation allows an organization to continuously monitor how the service meets the set objectives.18,19 Information obtained from the evaluations is used to inform the organizational leaders regarding necessary modifications. Next, modification is the extent to which the innovation is modified during an adaptation process.20 Research found that services that were modifiable were more likely to be sustained.1,2,19,21,22 Fourth, compatibility is defined as the extent to which in-house services fit within the host pharmacy in terms of staff pharmacists’ skills, physical resources, workflow, and organization mission. Several studies found that compatibility is necessary to increase sustainability of the service.15,22–24 Lastly, sustainability is defined as the attainment of long-term viability and integration of in-house immunization services within an organization.13 By definition, sustainability is not simply service continuation; it addresses the extent to which a service becomes integrated in the host organization.15,25,26 Synonyms for sustainability are routinization and institutionalization.2,27 The study model is organized by using the structure–process–output framework.11 Structure refers to the properties of the organization in which the in-house services are provided. Process is the adaptation process by which in-house services are formally evaluated and modified to fit within the host organization. Outputs are the results of implementing the in-house services and are classified as intermediary (the level of compatibility) and ultimate (sustainability of in-house services) outputs.
Objectives The goal of this study was to increase understanding of factors affecting sustainability of pharmacy-based patient care services. To accomplish this goal, in-house immunization services were used as an example of innovative patient care services provided by community pharmacies. The specific objective of this study was to explore the relationships among effectiveness of champions, formal evaluation, degree of modifications made to in-house services, degree of compatibility between in-house services and the host pharmacy, and sustainability of in-house immunization services, as identified in the proposed model (Figure 1).
Methods Study design and data collection
Data presented in this study were collected during stage 3 of a multistage study of pharmacy-based immunization serwww.japha.org
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Structure
Process
Output Intermediary output
Ultimate output
Formal evaluation Champion effectiveness
Modifications made to inhouse services
Compatibility between inhouse services and host pharmacy
Sustainability of in-house immunization services
Figure 1. Study model of sustainability of in-house immunization services vices in Washington State community pharmacies. The overall goal of the multistage study was to better understand the trend of pharmacy-based immunization services and to identify factors influencing the adoption and sustainability of immunization services. The unit of analysis was at the pharmacy level, and information was gathered from key informants of community pharmacies in three stages in 2003, 2004, and 2006–2007. Key informants of community pharmacies included pharmacy managers or pharmacists on duty who were able to answer questions related to immunization activities in their pharmacies. Study procedures and use of data received exempt status from review by the institutional review board of the authors’ institution. Data presented in this report were obtained from the stage 3 survey conducted in 2006–2007. Because stage 1 survey respondents served as potential stage 3 respondents, describing how stage 1 and stage 3 surveys were conducted is imperative. For the stage 1 survey, a postcard-size mail survey instrument was sent to all Washington State community pharmacies in 2003. Of the 1,143 survey instruments sent, 2 were undeliverable, 13 involved incomplete responses, and 315 were completed (27.6% response rate). Follow-up telephone calls were made with 262 randomly selected pharmacies that did not respond to the mail survey. Of the 262 pharmacies, phone numbers were incorrect for 21 and the telephone interview was completed for 211 (87.6% response rate). Thus, a total of 526 stage 1 participating pharmacies were obtained using a combination of mail and telephone surveys. Regarding stage 1 nonresponse bias, a greater proportion of pharmacies in the mail survey compared with the telephone survey reported being involved in in-house immunization services.28 This could be a result of in-house immunization service providers realizing the importance of the pharmacy-based immunizations topic29–33 and therefore were more likely to respond to the stage 1 survey promptly. From December 2006 to February 2007, a modified Dill502 • JAPhA • 4 9 : 4 • J u l / A u g 2009
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man method34,35 with a telephone reminder was used to conduct a stage 3 mail survey with stage 1 respondents. Of the 526 stage 1 responding pharmacies, a total of 36 pharmacies were excluded from stage 3 because of a change in physical address and/or ownership. This stage 3 survey consisted of five contacts: a prenotification postcard, a survey instrument packet, a thank you/reminder postcard, a reminder telephone call, and a replacement survey instrument packet. Mail contacts were sent via first-class mail. For pharmacies not responding to the survey after receiving the reminder postcard, reminder telephone calls were made with a limit of four call attempts per pharmacy. Study variables and measures
In the self-administered survey instrument, key informants were asked to identify whether their pharmacy offered in-house immunization services in 2006. If they did offer the services, key informants would then answer questions related to championing of in-house services, how in-house services were evaluated, the extent of modifications made to in-house services, level of compatibility between in-house services and their pharmacy, and level of sustainability of in-house immunization services. Questions used to measure these variables can be found in Appendix 1 (electronic version of this article, available online at www.japha.org). For example, for formal evaluation, key informants were asked how their in-house immunization services were evaluated. If they responded “yes” to either formal evaluation conducted by employees who were involved in providing services or formal evaluation conducted by management, their responses were coded as 1 (i.e., formal evaluation was conducted). The sustainability scale, consisting of six items, was modified from Goodman et al.25 Key informants were asked to rate degree of agreement with six items on a 5-point Likert-type scale (“strongly disagree” [–2] to “strongly agree” [2]); sustainability was the mean score of the six items. Journal of the American Pharmacists Association
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Principal-component analyses with varimax rotation based on eigenvalues greater than 1 were conducted to ensure that each scale had one underlying component. All study constructs, except formal evaluation, were assessed for internal consistency reliability using Cronbach’s alpha coefficient. Scales exhibiting alpha values greater than 0.70 were considered reliable.36 Data analysis
Data were analyzed using SPSS version 16.0 (SPSS, Chicago). Because this study investigated factors influencing the extent of sustainability of in-house immunization services (i.e., the extent to which pharmacies attain long-term viability and integrate in-house immunization services within the normal operations of their organizations), pharmacies had to provide in-house immunization services in 2006 to be included in the study. If a pharmacy discontinued its in-house services before 2006, it was not included. Descriptive statistics were used to describe characteristics of respondents. Further, proposed relationships in the study model were explored using linear regression analyses to assess both direct and indirect effects of variables in the study model. Because insignificant differences often exist between the results of logistic regression and linear regression when the dependent variable is a dichotomous variable,37 we simplified how results were presented in the study model by reporting results of a linear regression when formal evaluation was used as the dependent variable. The variance inflation factor (VIF) was calculated for each independent variable. VIF is a measure used to indicate the degree of collinearity of an independent variable with the other independent variables in the model. All statistical analyses were based on a significance level of 0.05. Nonresponse bias investigation
To assess nonresponse bias for the stage 3 survey, characteristics of stage 3 nonrespondents and survey respondents were compared. To collect nonrespondent data, telephone calls were made with 68 randomly selected pharmacies using a structured telephone script with an abridged version of the stage 3 mail survey instrument. The abridged telephone survey instrument collected information from key informants regarding their demographic information, pharmacy’s characteristics, and in-house service adoption status. Nonresponse telephone surveys were made with a limit of four call attempts per pharmacy. Analysis of variance and Pearson chi-square tests were used when respondents’ characteristics were continuous and categorical variables, respectively.
Results Stage 3 response rate, respondent characteristics, and nonresponse bias
Of 490 survey instruments sent, 1 was undeliverable, 2 were considered incomplete, and 206 were completed (response rate 42.1%). Table 1 describes characteristics of Journal of the American Pharmacists Association
stage 3 respondents. The majority of key informants were male (64.0%), held a BPharm degree (79.5%), were pharmacy managers (71.0%), and had completed immunization training (62.4%). Many participating pharmacies were independently owned (34.9%) or part of chain or mass merchandisers (41.9%). About two-thirds of participating pharmacies had one to two full-time equivalent pharmacists (66.9%), and about three-quarters reported an average daily prescription volume of fewer than 250 (75.3%). A total of 104 (54.2%) were in-house service providers in 2006. These 104 pharmacies were included in the regression analyses. Table 1 also describes characteristics of these 104 in-house service providers. For stage 3 nonresponse bias investigation, of the 68 randomly selected pharmacies that did not respond to the stage 3 mail survey, 7 pharmacies did not provide direct pharmacy services to the public and 3 had disconnected telephone numbers. Hence, of the 58 eligible pharmacies, 38 completed the telephone interview (response rate 65.5%). When characteristics of stage 3 respondents were compared with those who did not respond, the results revealed statistically significant differences in three variables (online Appendix 2). Specifically, among respondents, a greater proportion of key informants had a BPharm degree (χ2 = 4.799, df = 1; P < 0.05), held the owner/partner job position (χ2 = 6.322, df = 2; P < 0.05), and completed an immunization certification program (χ2 = 4.076, df = 1; P < 0.05). However, no statistically significant differences existed for the other eight variables. Descriptive statistics and reliability of constructs
Principal component analyses showed that each scale had one underlying component. The champion effectiveness scale, adapted from Hays et al.,38 was an exception; rather than loading on a single component, items in this scale loaded on two components. As a result, the decision was made to separate the eight items into two champion effectiveness subscales (online Appendix 1). The first subscale focused on broader leadership roles that supported in-house immunization services. It included questions related to the champion’s commitment to the pharmacy’s mission, ability to garner resources, ability to obtain collaboration from a physician, and advocating for the continuation of immunization services. The second subscale, on the other hand, focused on ability of champions to manage in-house immunization services and handle problems, if any arise. It included four items asking respondents to describe the person in charge of immunization services in terms of their leadership and guidance in the maintenance of in-house services, knowledge about immunization services, ability to manage conflict, and ability to solve problems and issues at the practice site. The first and second subscales are referred to as strategic champion effectiveness and operational champion effectiveness, respectively. A summary of the constructs, number of items per construct, reliability, mean (±SD), and scale range was www.japha.org
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Table 1. Characteristics of stage 3 respondents (n = 206) and respondents included in the analysis (n = 104) Variable Sex Male Female Pharmacy degree BPharm PharmD Job position Staff pharmacist Manager Owner/partner Completed immunization training No Yes Pharmacy ownership Single/multistore independently owned Chain/mass merchandiser Grocery/supermarket Clinic Pharmacists employed 1 FTE 1.1–2.0 FTEs >2.0 FTEs PharmD pharmacists employed None 0.1–1.0 FTE >1 FTE No. staff pharmacists trained in immunizations None One Two Three or more No. staff pharmacists who actively administer vaccines None One Two Three or more Average prescription volume per day 1–150 151–250 ≥251 Provider of in-house services No Yes Abbreviation used: FTE, full-time equivalent. a Totals may vary due to missing data. reported in Table 2. Reliability analysis for each scale revealed acceptable reliability. Reliability coefficient of strategic champion effectiveness was the lowest (0.71); nonetheless, it was considered acceptable.36 Unlike other vari504 • JAPhA • 4 9 : 4 • J u l / A u g 2009
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Stage 3 respondents No. (%)a
Respondents included in the path analysis No. (%)a
126 (64.0) 71 (36.0)
65 (64.0) 35 (36.0)
159 (79.5) 41 (20.5)
74 (73.3) 27 (26.7)
17 (9.3) 130 (71.0) 36 (19.7)
13 (14.1) 67 (72.8) 12 (13.0)
68 (37.6) 113 (62.4)
11 (12.4) 78 (87.6)
65 (34.9) 78 (41.9) 30 (16.1) 13 (7.0)
27 (28.7) 46 (48.9) 20 (21.3) 1 (1.1)
49 (24.3) 86 (42.6) 67 (33.2)
22 (21.8) 32 (31.7) 47 (46.5)
87 (52.1) 50 (29.9) 30 (18.0)
35 (40.2) 31 (35.6) 21 (24.1)
62 (30.7) 69 (34.2) 45 (22.3) 26 (12.9)
0 44 (42.3) 34 (32.7) 26 (25.0)
92 (45.8) 56 (27.9) 32 (15.9) 21 (10.4)
0 54 (51.9) 29 (27.9) 21 (20.2)
68 (35.1) 78 (40.2) 48 (24.7)
29 (29.6) 36 (36.7) 33 (33.7)
88 (45.8) 104 (54.2)
0 104 (100.0)
ables included in the study model, formal evaluation was a dichotomous variable (1, a pharmacy formally evaluated in-house services; 0, a pharmacy did not formally evaluate in-house services). More than one-half of pharmacies Journal of the American Pharmacists Association
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Table 2. Descriptive statistics and reliability of constructs (n = 104) Construct Items Reliabilitya Mean ± SD Possible scale range b 4 0.71 4.66 ± 0.50 1–5 Strategic champion effectiveness Operational champion effectivenessb 4 0.81 4.57 ± 0.54 1–5 Modifications made to in-house servicesb 5 0.84 2.77 ± 1.01 1–5 Compatibility between in-house services and the host pharmacyc 4 0.85 3.26 ± 0.96 1–5 Sustainability of in-house servicesd 6 0.83 0.76 ± 0.66 –2 to 2 a Cronbach’s coefficient alpha. b Each item measured by 1, not at all; 2, a little; 3, to some extent; 4, to a moderate extent; 5, to a great extent. c Each item measured by 1, very poor fit; 2, poor fit; 3, moderate fit; 4, good fit; 5, very good fit. d Each item measured by –2, strongly disagree; –1, disagree; 0, neither agree nor disagree; 1, agree; 2, strongly agree.
Table 3. Linear regression analyses in the proposed sustainability model (n = 104) Standardized coefficient Dependent variable: formal evaluation Strategic champion effectiveness Operational champion effectiveness Dependent variable: degree of modifications made to in-house services Strategic champion effectiveness Operational champion effectiveness Formal evaluation Dependent variable: degree of compatibility between in-house service and the host pharmacy Strategic champion effectiveness Operational champion effectiveness Formal evaluation Modifications Dependent variable: degree of sustainability of in-house immunization services Strategic champion effectiveness Operational champion effectiveness Formal evaluation Modifications Compatibility (51.6%) reported having a formal evaluation process in place. Relationships of key variables in the proposed study model
Of the 206 respondents, a total of 104 pharmacies that provided in-house immunization services in 2006 were included in the analyses. Figure 2 and Table 3 show results of linear regression analyses for the proposed sustainability model. In the analysis, when sustainability was used as the dependent variable, VIF for the independent variables ranged from 1.22 to 1.54, indicating that multicollinearity was not a problem. The regression model indicates that 42% of the variance in sustainability can be predicted from strategic champion effectiveness, operational champion effectiveness, whether a formal evaluation was conducted, degree of modifications made to inhouse services, and degree of compatibility (Table 3). Compatibility between in-house services and the host pharmacy was the only significant predictor of sustainability of in-house serJournal of the American Pharmacists Association
P
0.26 –0.11
0.038 0.362
0.05 0.05 0.31
0.705 0.698 0.005
0.12 0.31 0.20 0.26
0.300 0.005 0.049 0.009
0.00 0.09 0.19 0.16 0.45
0.978 0.419 0.050 0.091 0
R2 0.05
0.11
0.32
0.42
vices (P < 0.05). The path coefficient (0.45) indicates that for every unit increase in the degree of compatibility, the degree of sustainability of in-house services was increased by 0.45 units. Using compatibility as the dependent variable, the model reveals that 32% of the variance in compatibility can be explained from strategic and operational champion effectiveness, formal evaluation, and modifications made to in-house services. Further, the statistically significant path coefficients using compatibility as the dependent variable were 0.31 for operational champion effectiveness, 0.20 for formal evaluation, and 0.26 for degree of modifications made to in-house services. With modifications made to in-house services as the dependent variable, the model shows that 11% of the variance in degree of modifications can be explained using strategic and operational champion effectiveness and whether a formal evaluation process was used. The only statistically significant path coefficient was 0.31 for formal evaluation. In the analysis, when formal evaluation was used as the dependent variable, strategic champion effectiveness was a sigwww.japha.org
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0.00 0.12
Strategic champion effectiveness
0.26a
Formal evaluation
0.20a
–0.11 r = 0.50b Operational champion effectiveness
0.31b 0.05 0.05
Modifications made to inhouse services
0.26b
0.19 Compatibility between inhouse services and host pharmacy
0.45b 0.16
Sustainability of in-house immunization services
0.31b 0.09
Figure 2. Standardized path coefficients for sustainability of in-house immunization services model a P < 0.05. b P < 0.01. nificant predictor, with the statistically significant path coefficient of 0.26. The result was confirmed with a logistic regression. No differences in the conclusion between the linear and logistic regression analyses were found. With each additional unit increased in strategic champion effectiveness, the odds of using a formal process to evaluate in-house services (versus not having a formal process) increased by a factor of 3.36, controlling for operational champion effectiveness.
Discussion This study examined factors facilitating sustainability of pharmacy-based patient care services. Drawing from the program sustainability framework2 and the structure–process–output framework,11 the proposed model conceptualizes how a pharmacy can sustain in-house immunization services. Sustainability, in this study, is defined as the attainment of long-term viability and integration of in-house immunization services within the normal operations of an organization.13,15,25 Results revealed that compatibility was a predictor of the sustainability of in-house immunization services. This is consistent with other studies that suggested compatibility between the innovation and the host organization is necessary.13,15,22,24 That is, if in-house immunization services fit well with the pharmacy’s mission, objectives, and routines, they are likely to remain viable. Results further suggest that to achieve the desired level of compatibility, two pathways can be followed. The first pathway emphasizes the importance of in-house immunization services undergoing an adaptation stage to enhance compatibility between in-house services and the host pharmacy. The adaptation stage involves two components: a formal evaluation and modification process. After in-house immunization services are implemented, formal evaluations are conducted. Informa506 • JAPhA • 4 9 : 4 • J u l / A u g 2009
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tion obtained from the evaluations is then used to recommend to the organizational leaders whether any modifications need to be made to the in-house services. Conducting formal evaluations and making modifications to in-house immunization services will result in a greater degree of compatibility between the host pharmacy and in-house services. We recommend conducting formal evaluations regularly because an innovation must be adapted to new needs and circumstances if it is to continue.16 Generally, in this pathway, a strategic champion who possesses a general supportive leadership role has a considerable effect on implementing a formal evaluation. Unlike the first pathway, in-house immunization services do not go through the adaptation process. That is, with the second pathway, a host pharmacy implements in-house immunization services in a way that is compatible with the current workflow, staff skills, pharmacy resources, and pharmacy mission. Generally, a pharmacy that follows this pathway has an operational champion who possesses knowledge about inhouse immunization services and has an ability to handle problematic issues, if any arise. Given the knowledge related to inhouse services and ability to manage and handle problematic issues, the champion can decide how in-house services should be scheduled (e.g., walk-in versus appointment, year-round versus seasonal), what type of vaccines should be offered, how many employees should be involved, and how space/privacy area should be used. Operational knowledge is found to be helpful in selecting a compatible format of in-house immunization services without the need for any modifications. The second pathway can be used as a substitute for or as a complement to the adaptation process but perhaps is not essential. Although this research study has focused on in-house immunization services, the proposed model and findings may be applicable to other pharmacy-based innovative practices such Journal of the American Pharmacists Association
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as medication therapy management services and tobacco-cessation programs. We recommend that organizational leaders and practitioners consider the key factors in the study model and incorporate them as an integral part of the program planning and implementation processes. Doing this may foster sustainability of innovative services. This study may also benefit researchers who seek to sustain interventions beyond the intervention period. Our findings offer an explanation that incompatibility between the intervention and the host pharmacy may be a reason why some innovative services were not sustained.39,40 Researchers should have sustainability as a consciously planned goal rather than a latent goal. To foster sustainability, the researchers must determine how best to enhance the compatibility between the intervention and the host pharmacy. If the intervention seems to be compatible with the current pharmacy operations, the intervention likely will be sustainable. If, however, the intervention does not seem compatible, the researchers must ensure that formal evaluations are conducted and modifications to the intervention can be made to enhance the sustainability of the intervention. Because making changes to the intervention during the intervention period may jeopardize the validity of the intervention study, we recommend implementing a modifications plan immediately after the intervention period. Finally, ceiling effects were observed in both strategic and operational champion effectiveness subscales (mean 4.66 and 4.57, respectively). Despite the low variability in responses for these two subscales, we still found a significant relationship between strategic champion effectiveness and formal evaluation and between operational champion effectiveness and compatibility. We recommend that future researchers refine these subscales by reducing the ceiling effect and reexamine the effects of champion effectiveness on sustainability of in-house immunization services.
Limitations The first limitation of the current study was related to the use of key informants as a source of information, as they were subject to recall errors and may have limited knowledge of the survey topics. Second, because of the cross-sectional nature of the study design, causal inferences should be made with caution. Next, this study investigated the effects of only particular factors; all factors possibly influencing sustainability were not evaluated. Further, this study did not include pharmacies that already abandoned in-house services; therefore, it did not identify factors related to the abandonment of in-house services. Future research should include an investigation of reasons for service discontinuation as its priority area. Finally, the study may have limited generalizability to the nonrespondents in Washington State, to states other than Washington, and to other innovations.
Conclusion This study investigated factors fostering sustainability of in-house immunization services in community pharmacies. Organizational leaders and practitioners had the potential to Journal of the American Pharmacists Association
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