Culture: The Missing Piece

When I graduated with my pharmacy degree all those many years ago, I came out trained to be a pharmacist.  Nowhere in my education was I taught how to be a leader.  Yet many pharmacists are thrust into the position of pharmacy manager or leader of the dispensary team and many more choose leadership as owners of their own practice.  When I started out as owner/manager six years ago I had no idea how to manage “people”, yet I soon discovered that productivity in the dispensary is at its highest when pharmacy teams work as a cohesive unit. I also quickly learned that being a leader is tough because it means managing a group of people, each with their own personality, history, experience, skills and challenges. 

Most often as managers/owners we focus on strategic planning, goals, getting “stuff” done, and sometimes cannot understand why our plans are not well implemented, why execution is lagging and negativity abounds.  Most often this is due to not understanding the power of culture.  Group culture is one of the most powerful forces on the planet, yet it is difficult to define.  We can sense when a strong group culture is present in successful businesses, championship teams, or philanthropic causes, and we sense when it is absent or toxic.  According to a Harvard study of over 200 companies, a strong culture increases net income 765% over 10 years. 

What is culture?  It is the tacit social order of an organization: It shapes attitudes and behaviors in wide-ranging and durable ways. Culture defines what is encouraged, discouraged, accepted, or rejected within a group.

Why is a strong common team culture important?  Because it correlates with levels of employee engagement and customer orientation; and both employee engagement and customer orientation correlate with productivity and profitability in business. 

If a team or business culture is properly aligned with staff’s values, drives, and needs, culture can unleash tremendous amounts of energy toward a shared purpose and foster a business’s capacity to thrive.  Cohesive culture allows creativity to flourish. Problem solving is innovative, identification of inefficiencies comes from the ground level as all team members strive to achieve common goals.  Leaving team or business culture to form on its own can confound strategic goals and lead to poor performance and dissatisfaction in employees which ultimately leads to unhappy patients/customers.  A pharmacy team culture that has been left to form on its own tends to be negative and staff’s internal dialogue can look something like this:


“That customer is difficult, I’m just going to put my head down and hope the other staff will take that prescription.”
“Why am I working so hard? He’s over there being so slow.”
“I don’t understand this. I’ll just leave it for the next shift.”
“I wonder if Pharmacy X is a better place to work?”

“I’m just going to use the washroom- but really I’m going to check my phone.”

Culture is not tangible, so how does it work?  We tend to think about it as a fixed trait, like DNA, some groups just have it and some don’t.   This however is not the case.  Team culture can be shaped and managed.  The first and most important step leaders can take to maximize the value of team culture and minimize its risks is examine and understand their business’s culture and assess its intended and unintended effects.  What is the implicit social order, the values, leadership style and team dynamics?  Once the culture is understood, leaders can work on shaping and changing team culture to align with the goals and strategies of the organization.  Successful change requires leaders themselves to align with the culture they wish to espouse.  Organizational conversation must underscore the change and so must organizational design.  As employees start to recognize that their leaders are talking about different business outcomes—for example patient care or innovation instead of revenue or quotas—they will begin to behave differently themselves, creating a positive feedback loop and ultimately meet and exceed the organizations goals. 

 “Leading with culture may be among the few sources of sustainable competitive advantage left to companies today.”  Harvard Business Review 

Resources:

  1. Start with Why: How Great Leaders Inspire Everyone to Take Action by Simon Sinek
  2. The Culture Code: The secrets of Highly Successful Groups  by Daniel Coyle
  3. The Culture Factor  Harvard Business Review.  HBR.org 
  4. Leader’s Eat Last: Why some teams pull together and others don’t.  by Simon Sinek.  Penguin 2014
  5. Corporate Culture and Performance  by James Heskett and Dr. John Kotter. Harvard Business School.

Where’s the Passion?

My oldest son entered his first year of university this year and it has been amazing to witness his excitement and passion for learning and the drive to achieve his goals.  It has me looking back at my own university days, over 20 years ago, and the ensuing years that have past.  What did I expect from working so hard to be a “pharmacist” all those years ago and where am I now?

I remember what it was like sitting in a lecture hall, in classes I enjoyed (admittedly medicinal chemistry may perhaps be excluded here!)  While it was incredibly hard work, I loved it!  I loved learning the newest drug studies and guidelines for disease management. I also remember those early years of pharmacy practice, fresh out of school, being so excited to get into the real world and apply my skills caring for patients.  Even 25 years ago we were talking about “Pharmaceutical Care” and “expanded scope of practice”.

It didn’t take long however before discouragement set in and I felt stuck in a rut of checking endless prescriptions.  I spent over ten years of my professional career mostly just “doing my job”, and I will admit, slowly drifting into apathy.  I did my job accurately, but I was not passionate about it. I also did the minimum amount of CEUs every year, never remembering the learning or applying it to practice.  One year I even had the College respond to my continuing education submission with the comment that it seemed “ lacking in thought ”  and rather “hastily put together”,  and they were right!  I wasn’t engaged, I had no passion for the practice or for continued learning.

I often complained I didn’t have the time to look after patients properly, however, when I did have time I did not extend myself to proactively engage patients.  I eventually asked myself the tough question:  If I was given the perfect circumstances, all the time I needed, the ideal practice setting…would I be able to do the job I wanted to?  Could I take responsibility for patients medication management, solve drug therapy problems, engage patients proactively rather than waiting to be asked questions?  I wasn’t sure.  I was so rusty from the many years of the prescription checking tread mill that I was hesitant and frankly afraid to step out of the role of just technically checking prescriptions.

I share this rather embarrassing segment of my career as I feel many pharmacists are stuck in their practices.  When I read comments on blogs and have discussions with colleagues at conferences, I hear the resounding theme that pharmacists, even just a few years out of school, have lost their passion for pharmacy practice.  There are numerous outside factors that contribute to this including corporate decisions, government cutbacks, drastic cuts in drug pricing, third party pressures, etc.  But I think we as a profession also need to acknowledge our own contributions to this state of the profession.  Apathy abounded even in the “good” years, in the years where pharmacists were being offered starting bonuses, had shift overlap and high wages.  It’s been decades of pharmacists not stepping into their role, merely talking about how important we are rather than demonstrating it in our pharmacies.

So now we face a time of crisis where artificial intelligence and automation can take over pharmacists role, and the drive towards cheaper, faster and more convenient drug access will radically disrupt traditional community pharmacy.

I don’t claim to have all the answers, or really any at all.  I continue to write and speak and engage colleagues because I’m just not ready to give up.  I’m not ready to retire my white coat and send my patients to the “Amazons” of the world.  Despite it being rather vulnerable to put myself out there in discussing pharmacy practice on a national platform, the dialogue is essential.

Where am I now?  In the ensuing years since that wake-up call I radically changed my practice, and eventually hired on support staff and pharmacists who have the same vision and passion and are willing to practice in an environment I am proud to have created.  Have I encouraged my son to pursue pharmacy as a career?  I will admit that in his earlier years I did, but as he got older and Engineering more suited his interest I was relieved.  I don’t know where pharmacy is headed, it isn’t looking good, but giving up for me is not an option.  I still need to find passion in my work, a reason to get out of bed in the morning, and that reason is the patients in our care and the development of my incredible team that looks after them.

What’s In Store : The Future of Pharmacy Practice

Future Up ahead sign

cc licensed ( BY SA ) flickr photo by OTA Photos: http://flickr.com/photos/101332430@N03/9681096812/

 

During an interview last week I was asked what pharmacy practice would look like 5-10 years from now. Seems to be the burning question these days…..change is here (whether we want it or not!)

  • rebates are disappearing
  • financial pressures are increasing
  • alternative reimbursement structures are popping up in every province
  • expanded scope of practice is moving forward
  • new roles for technicians

When the dust settles, where will the practice of Pharmacy end up?

The various points of influence and pressure are propelling pharmacy practice towards the focal point of patient assessment.

Of course, assessment has always been a part of pharmacy, usually coming second to dispensing, but we’re at the cusp of seeing assessment become our driving focus.

What do I mean by that?

Historically, decisions on drug therapy have mostly been made by physicians, dentists and more recently, nurse practitioners. Pharmacists have assumed the prescription was appropriate and should be the best drug for the patient. Our role was to maximize the benefit and reduce the risk for the patient (by checking dosing, drug interactions, counseling and suggesting compliance strategies, etc.)

This jived well with profitability in community pharmacy which has historically been fueled by filling prescriptions as fast as possible. Most pharmacists, overwhelmed with the basic necessities of checking the processing and accuracy of the prescription, have not been given the time or workflow ability to assess the patient.

One of a pharmacist’s main responsibilities has always been to assess whether a drug is appropriate for the indication and is indeed the best choice for that patient. It’s a core standard of practice, but one that hasn’t reached it’s full potential. (A practice consultant at the College of Pharmacists in Alberta recently told me she “almost never” sees a notation on the prescription about the patient’s indication.)

As the pressure to change increases and pharmacy moves forward, what we will see is pharmacists taking on the role more and more of prescriber, and at the core of prescribing is patient assessment.

We are seeing this already in the ability to extend, adapt or change a prescription. This role is expanded in some jurisdictions with the ability to apply for full prescriber or initial prescribing status.

However, the uptake in adapting/prescribing has been slow in provinces where pharmacists have the ability to do so. Billing statistics show that pharmacists will more easily extend (renew) a prescription rather than change one. They will also more easily extend a prescription for one week than for three months. It seems the more assessment required (and the more risk), the less likely pharmacists are to prescribe.

Prescribing DOES involve more risk. It also requires time to assess a patient and do the proper documentation to go along with it. So in an already busy practice, why is this change in practice paradigm coming and why should we care?

Here’s why:

Good for PROFITABILITY

Let’s face it, we don’t have a job if our pharmacies are not profitable. It doesn’t matter if you are independent or corporate, staff or owner. Health care is a business and no business survives running in the red. Right across the country pharmacy sustainability is being shaken up. Profitability of pharmacy has always rested on script count. The more prescriptions we could pump out, the more profitable we were. This led to pharmacists coming out of school, being thrown into primarily a dispensing role, and over the years losing their clinical skills and confidence in patient assessment. Some pharmacists even found themselves being told by employers to “cut down on counseling” to get back to checking.

With rebates disappearing, the profitability of the prescription mill is going down. However, reimbursement for expanded clinical services is increasing. Being reimbursed to extend, adapt, assess, independently prescribe, do med reviews and follow ups, treat minor ailments, etc will put financial pressure on pharmacy practice to change. To provide these services efficiently, our assessment and documentation skills need to be dusted off and sharpened up.

Good for PATIENTS

Pharmacists as prescribers are in a very unique position. We have immense background knowledge of evidence based practice, clinical guidelines, drug availability, plan coverage and clinical experience with patient factors such as kidney function and weight. We can see the entire picture for that patient, for the third party payer and for our practice. Indeed, that puts us in the best position for deciding on drug therapy for our patients.

Pharmacists as prescribers also have the best arsenal to improve patient adherence. The ability to change a patient’s therapy and follow up in a timely manner provides efficient patient care which improves patient satisfaction with their therapy (which increases adherence). Providing short supplies of new medications, following up and then adjusting a patient’s dose, regimen, or switching to an entirely new medication results in a tailored drug regimen that fits with the patient’s lifestyle, expectations, drug coverage and overall medication regimen. This actually goes beyond adherence as you are partnering with the patient to provide shared care.

A quick example: Patients starting on gabapentin for neuropathy often stop therapy due to adverse effects or perceived ineffectiveness. It is time consuming and frustrating to book appointments over and over again with a physician until the dose is adjusted correctly. Patients will often give up due to adverse effects or thinking it just isn’t working for them. If that patient is followed up every week by their pharmacist, the pharmacist can work with the patient to fine tune therapy. (Experiencing too much drowsiness? Slow down on the taper up. Tolerating fine but pain relief not there? Taper up towards max dose.) We can fine tune a patient’s medication, improve adherence and bill for follow up services which makes the service profitable.

Good for THIRD PARTY PAYERS and GOVERNMENT

No shocker here, but government and third party payers want to save money. We’re constantly hearing that drugs are the leading driver of rising health costs. Pharmacists are in an ideal position to save payers HUGE dollars. (Your patient needs an ACEI. Should you choose Mavik or ramipril, both of which have the same therapeutic response?) When most pharmacists consider cost they are usually looking at what it is going to cost the patient. Not as much thought goes into what it is costing the third party payer. (If Mavik and ramipril are both covered, the cost difference to the patient is often minimal. The cost difference to a third party payer over time is immense.) Pharmacists have extensive background knowledge on drug cost and evidence based interchangeability (as opposed to just pharmacokinetic interchangeability). It’s the ability to save the patient and the payer huge dollars. There is a big role for pharmacists that third party payers are missing. The ability for pharmacists to save on drug costs is an emerging partnership that will have greater impact as pharmacist prescribing continues to increase.

We know change is upon us. In a nut shell, we are going from “How do I make someone else’s choice of medication work best for this patient” to “What IS the best choice of medication therapy for this patient” and taking an active role in assessment, prescribing and adjusting patients’ medication therapy.

Guaranteed that every pharmacist could name several barriers to this change in practice. Conversations with colleagues and implementing change in my own practice has uncovered many obvious and not so obvious ones. There is no doubt that much needs changing in the structure of our practices and the environment of health care to facilitate pharmacy moving forward. These will be looked at in “Navigating Change in Pharmacy Practice.”

Picture this: FUTURE PRACTICE

Pharmacist is sitting at an intake desk. Patient sits down and pharmacist proceeds with assessment. “What did you see your doctor for today?” Pharmacist assesses indication, history of chief complaint, and (if not already on file) any allergies, medical conditions and current meds. Pharmacist checks the provincial system for additional information (labs, kidney function, medications), decides the ciprofloxacin being prescribed is not a good choice given patient’s advanced age and medications. As well, the UTI ( without a urine screen) is better treated empirically with cefixime. Pharmacist can adapt the Rx, bill for the assessment and counsel at intake. The patient is handed the pharmacist’s business card and advised to call if any issues crop up with the therapy and the pharmacist enters a phone follow up reminder into the computer software to pop up in 7 days. The pharmacist writes up the adapted prescription and passes the Rx back to a technician and doesn’t see it again. The pharmacist then moves onto the next patient.

This may sound unreal in a busy pharmacy where patients are lined up. However, the current work flow set up with the pharmacist at the back end of dispensing is highly inefficient and unprofitable with the new framework. If a drug related problem (DRP) is uncovered when checking or counseling, or the patient requires additional therapy or it really should be a refusal to fill….. think of all the time wasted inputting, processing, preparing… perhaps for nothing! And all that time the patient waited; only to wait again after you assess their drug related problem and provide them what they REALLY need. The biggest problem with pharmacists at the back end of work flow is that the majority of DRPs are completely missed due to a lack of patient assessment….and so are the billing opportunities.

It requires a paradigm shift in the role of the pharmacist. A lot of time is wasted in pharmacy by the pharmacist only coming in at the end to check and counsel. That time can be put in at the front end. It requires a change in employer and patient expectations. Yes, it may take longer at intake, but that pharmacist may provide professional services billing that exceeds dispensing fees, gains a loyal patient and provides more billing opportunities by scheduling follow ups into the system during assessment. Once used to the change, patients are more than happy to wait when they know they will have a conversation with the pharmacist and be assured their therapy is appropriate.

Assessing a patient can also seem time consuming, especially when you are not accustomed to this type of work flow. However, like anything, the more you assess and document, the more comfortable it becomes and more efficient the process. Pharmacist initial assessment of the patient is necessary for the new framework to be profitable. It cannot be left up to the technician to decide if there is a problem or expanded service billing opportunity. At intake the pharmacist can immediately assess the appropriateness of the prescription in front of them, the needs of the patient, can pull up patient history and determine right then what is needed. Does the patient need an adapt? Do they need an additional drug prescribed? Do they need nothing at all today? Do they need a med review scheduled? Do your previous notes indicate they’re due for an A1C? Was there a missed follow up that can be completed and billed? When was their last blood pressure check?

A quick example: If you’re at intake, it’s easy to assess a patient who has high cardiovascular risk being prescribed diclofenac for acute pain as benefiting from a change to naproxen. Adapting that Rx is within every pharmacists’ scope of practice in Alberta (and most provinces, if not now, then in the future). So you’ve improved patient care, reduced risk, and billed for a professional service. (And that Rx was handed off to the tech, and given to the patient on the back end because you’ve already counseled them during your assessment.)

As pharmacists get more used to documenting and triage this takes less and less time. The pharmacist can then write up a prescription (and note which clinical service to bill), or if deemed the Rx is fine, send it back to the tech to prepare and have it checked by a registered technician. Technicians on the back end of pharmacy makes sense. Technicians can teach patient devices like inhalers, blood pressure and blood glucose meters, how to draw up liquid medications, etc. These are all technical functions. When fortunate enough to have pharmacist overlap, the second pharmacist can handle any unanswered questions. Most often, with this type of patient care, additional questions or problems that may come up can be answered in a phone or email follow up (and billed as a follow up service).

It can be comfortable being in the back of the dispensary, being called forward by a technician for counseling or if they encounter what they determine to be a problem. Assessing at intake can seem daunting if you feel out of practice or it’s out of your comfort zone. However, steps can be taken to develop skills, knowledge and confidence while pharmacists are still at the back end, to prepare for the shift to more focused patient assessment.

I would argue that pharmacists are returning to the role they were trained for. Pharmacy schools are preparing their grads for patient assessment and drug therapy decision making. Many of them are coming out ready to embrace that role. What they are finding is that the the majority of practices have not changed.

However, the financial pressures and changing reimbursement and scope of practice structures will force change. We MUST change for the profession to be viable. Technicians can dispense, check prescriptions, teach devices and manage inventory. More and more patients use mobile devices or the internet to learn about their drugs. Assessing drug therapy, tailoring a patient’s drug regimen, solving drug related problems and providing timely follow up is a pharmacist’s expertise, and an essential component of health care that cannot be replaced.