Executive Summary...i. 1. Introduction Organizational Structure, Role, Authority, and Accountability Recruitment and Retention...

Transcription

1 Initiative 6 Allied Health Project 6.2 Regional Pharmacy Model May 2004

2 Table of Contents Sections Executive Summary...i 1. Introduction Organizational Structure, Role, Authority, and Accountability Recruitment and Retention Drug Distribution Clinical Pharmacist Support Adequate Pharmacy Staffing Levels Communication Plan ABC 6.2 Pharmacy Regional Model Team Members...60 Appendices Appendix 1 Resource List...61 Appendix 2 Proposed Regional Pharmacy Program Organizational Chart...63 Appendix 3 Regional Pharmacy Managers Survey...64 Appendix 4 Regional Pharmacy Model Survey Results...68 Appendix 5 Regional Pharmacy Program Career Ladder...70 Appendix 6 ABC Staffing Adjustment Financial Plan...73 Winnipeg Regional Health Authority, 2004

3 Executive Summary With the regionalization of Winnipeg s hospital-based health care services in 1998, the opportunity existed to not only address facility-specific pharmacy needs, but also to realize the potential for a more effective and efficient Regional Pharmacy Program. It was envisioned that pharmacy services could be reorganized in such a way that it would be possible to exploit the opportunities that exist for sharing of resources, reduce duplication of effort, and standardize pharmacy services within the Winnipeg hospital system. In an effort to realize this potential, pharmacy services were organized as a regional program in 1998 and a new organizational model for pharmacy was created. Looking back six years later, in 2004, the management model developed in 1998 has proven to have both its strengths and its weaknesses. Many accomplishments can be attributed to the model, including significant regional improvements and standardization of services in the portfolios managed by each of the Regional Pharmacy Managers. However, a number of model-related issues have been identified over the last six years. An external review of the Regional Pharmacy Program in 2001 (Wilgosh/Hunter Review 1 ) identified a number of these issues and provided recommendations for addressing these problems. Some of the recommendations were accepted and implemented while others, notably those that dealt with the reporting relationships within the Regional Pharmacy Program, were not implemented at that time. In 2002, as part of a larger benchmarking review of the WRHA, an external review of the Regional Pharmacy Program was conducted by Deloitte and Touché. With respect to the Regional Pharmacy Program the External Review identified: A need to provide clear direction for the role and authority of the Regional Pharmacy Program team in comparison to the roles and authority of the site pharmacy program teams. A need to reduce the barriers between the Regional Pharmacy Program and the site-based pharmacy programs through improved communications and reduced competition. That pharmacy staffing levels at most facilities within the WRHA are below peer levels. Winnipeg Regional Health Authority, 2004 i

4 A need to make manpower investments at acute care sites. Shortterm/immediate reinvestment is recommended at SBGH. A shortage of pharmacists throughout the health care system. An increasing demand for clinical pharmacist support. A need to formalize a regional approach to recruitment and retention of pharmacists. That more efficient drug distribution processes within the pharmacy program could free up pharmacist resources and allow them to be redirected from drug distribution to clinical roles. That at some sites, nursing staff expend considerable time ordering, stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems. The need for ongoing leadership and professional development of regional program teams. The ABC Regional Pharmacy Model Project Operating within the framework of the Achieving Benchmarks through Collaboration (ABC) Project, the Regional Pharmacy Model Project was requested to: Develop a regional philosophy and organizational model for the pharmacy service. Develop a model for providing all sites with a safe, effective and efficient drug distribution system, accompanied by an appropriate level of clinical pharmacist support. Develop a regional approach to recruitment and retention of pharmacists to address vacancy issues in the profession system-wide. Develop a plan for reinvestment in pharmacy support at all acute care facilities to insure that pharmacy staffing levels are at national benchmark levels that are deemed sufficient to support the provision of quality pharmacy services. Project Methodology In order to accomplish the above objectives, the ABC Pharmacy Project Team undertook the following activities: Review of relevant resource material Received presentations from other WRHA regional programs Surveyed site/regional pharmacy managers Received presentations from Regional and Site Pharmacy Managers Winnipeg Regional Health Authority, 2004 ii

5 Surveyed six other major Canadian health regions Reviewed the ongoing work of the Pharmacy Regional Program. Alignment with National Patient Safety Initiatives It is worth noting that the implementation of these recommendations would serve to align the Regional Pharmacy Program s focus with patient safety initiatives that have recently been recommended by the Canadian Society of Hospital Pharmacists (CSHP). In their December 2003 position paper, entitled Impact of Hospital Pharmacists on Patient Safety 2, the CSHP reviewed the published literature on the impact that pharmacy services have on patient safety and concluded with the following statement and recommendations. Persistent efforts and continued system improvements are required to ensure patients are as safe as possible within our facilities. 2 To that end, CSHP recommends that all stakeholders and decisionmakers work together to accomplish the following: 1. Address (pharmacy) staff shortages within our health care facilities 2. Increase involvement of pharmacists in direct patient care activities 3. Improve drug distribution systems 4. Expand use of technology and automation 5. Increase use of computerized prescriber order entry (CPOE) systems 6. Improve medication-related adverse event reporting and analysis 7. Foster a collaborative approach to adverse event prevention All of these recommendations on patient safety are addressed either directly or indirectly in the ABC Pharmacy Project Team recommendations. Alignment with Other ABC Nursing Related Initiatives The Deloitte and Touché External Review identified that, at some sites, nursing staff spend considerable time ordering, stocking, and preparing medications as a result of inadequacies in the existing drug distribution systems. In addition, ABC Project 2.3 Care Delivery and Staffing, surveyed sites in the WRHA to assist with the redesign of nursing roles within the region. The enablers identified included pharmacy unit dose, Pyxis, and CIVA (centralized IV admixtures). Winnipeg Regional Health Authority, 2004 iii

6 The Pharmacy Project Team concurs with the findings of the External Review and the Care Delivery and Staffing Project Team, and believes that expanded unit dose/iv admixture services would significantly reduce the time that nursing staff currently spend performing medication-related activities. The Pharmacy Project Team also believes that the literature supports the positive impact that decentralized pharmacists activities have on nursing workloads. A number of the recommendations of the Pharmacy Project Team support ongoing WRHA Pharmacy initiatives aimed at expanded provision of unit-dose, automation of the drug distribution systems, and delivery of decentralized clinical pharmacist services. The Pharmacy Project Team believes that improved nursing staff efficiencies to those reported by peer hospitals, most of which have unit dose/iv admixture systems and higher levels of clinical pharmacy staffing, will be difficult to achieve without the implementation of the changes contained in this report. Action Requested of the ABC Steering Committee 1. Green Recommendations - Approval of those recommendations which have no ABC financial implications, and which can be implemented within the constraints of the existing WRHA/facility operating agreements; specifically recommendations numbers 7, 8, 9, 11, 12, 13, 15, 16, 18, 19, 20, 22, 23, 28, 29, 31, 32, 33, 34, 39, 40, 41, 42, 43, 44, and Yellow Recommendations - Referral, to Senior Management of the WRHA, of those recommendations that require major policy decisions and/or are difficult or impossible to implement within the context of the existing WRHA/facility operating agreements; specifically recommendations numbers 1, 2, 3, 4, 5, 6, 25, 26, and Red Recommendations - Tabling, for future action, those recommendations that have financial implications and cannot be implemented until reinvestment opportunities arise as a result of savings achieved through other ABC initiatives; specifically recommendations numbers 10, 14, 17, 21, 24, 30, 35, 36, 37, and 38. Winnipeg Regional Health Authority, 2004 iv

7 Recommendations Organizational Structure, Role, Authority, and Accountability #1 Yellow That Site Pharmacy Managers be directly accountable to the Regional Director of Pharmacy and be employed by the WRHA. Site Pharmacy Managers would have day-to-day responsibility for ensuring that their particular site s pharmacy related needs were being met, and would have matrix reporting accountability to Site Senior Management with respect to established service expectations. #2 Yellow That the Regional Director of Pharmacy be responsible for the performance evaluation of site managers, with input requested from each site CEO/COO at the time of the performance appraisal. #3 Yellow That all pharmacy staff in the region become employees of the WRHA. Note: The Project Team recognizes that support from Human Resources will be required to assist with implementation and ongoing support of this recommendation. The WRHA Human Resources Division is in the best position to advise if incremental WRHA HR resources would be necessary to support this change. #4 Yellow That site pharmacy budgets for pharmacy staff and supplies be consolidated into a single regional budget, managed by the Regional Pharmacy Program. Note: The Project Team recognizes that support from Finance personnel will be required to assist with implementation and ongoing support of this recommendation. The WRHA Finance Division is in the best position to advise if incremental WRHA Finance resources would be necessary to support this change. Winnipeg Regional Health Authority, 2004 v

8 #5 Yellow That the Regional Director of Pharmacy, in addition to his/her direct reporting relationship to the WRHA, have a matrix accountability to the site CEOs/COOs for the overall pharmacy services provided at each site. #6 Yellow That the Regional Director of Pharmacy establishes a working relationship with site CEOs through regular meetings held at least quarterly or more frequently as required. The purpose of the meetings would be to discuss site and regional pharmacy issues, to inform regarding regional initiatives, and to solicit input as to the effectiveness of the pharmacy program. #7 Green That a site/regional team decision-making model be adopted by the Regional Pharmacy Program that enables the team to make decisions that are binding on, and supported by, all members of the group. Principles would be developed to define the level of support (i.e. simple majority, consensus, unanimity) that was required for specific types of decisions. The need for unanimity would be reserved for exceptional circumstances. All team members would be held accountable for supporting and implementing group decisions. #8 Green That participation in WRHA approved initiatives undertaken by the Regional Pharmacy Program be mandatory at all sites, not optional. #9 Green That shared Site Pharmacy Manager positions be eliminated, and replaced by a full-time or part-time Site Pharmacy Manager position, based on the level of management responsibility at each site (e.g. staffing numbers, regional responsibilities, etc.) Note: The implementation of this recommendation would require funding for 2 to 2.5 additional management positions. The Project Team believes that this funding should eventually be part of the 45.2 FTE positions that have been identified as being required to bring the regional pharmacy staffing to the national mean benchmark level. However, given that there is unlikely to be new funding available to the Regional Pharmacy Program Winnipeg Regional Health Authority, 2004 vi

9 in the immediate future from the ABC Project, other options for funding this change have been explored. Following discussion of this issue with the CEO and other senior managers at the VGH and GGH sites, agreement was reached that the pharmacy management issue needed to be addressed in the immediate short term. At those two sites (the VGH and GGH) there has been a persistent pharmacy vacancy problem, attributed in part to a deficit in pharmacy leadership at those sites. As a result, the Regional Pharmacy Program, the GGH, and the VGH are proposing that the funding required to have a dedicated pharmacy manager at each site be extracted from the vacant pharmacist positions at each site. Although this will reduce the total number of staff pharmacist positions at the VGH and GGH, it is not anticipated that this will have a major negative impact on the existing staff pharmacist workloads for several reasons. To begin with, the positions from which the funding will come have been persistently vacant for over two years. In addition it is anticipated that 25% to 50% of the Site Pharmacy Manager s time at these sites will be committed to relieving front-line pharmacists of management activities that they have been assigned to perform in the absence of a full-time Site Pharmacy Manager at their site. By establishing a strong site pharmacy management presence it is hoped that the changes needed to create a highly desirable work environment for pharmacists at these two sites can be established. There are no short-term financial implications of this change. The funding extracted from staff pharmacist positions will be sufficient to fund the increase of 0.5 FTE Site Pharmacy Manager at the GGH and the VGH. The VGH and GGH have agreed to this arrangement with the understanding that a high priority will be given to replacing the reallocated staff pharmacist funding, when ABC funding for the regional shortfall of 45.2 FTE pharmacy positions begins to flow. It is hoped that a similar change to full-time Site Pharmacy Managers could be made at the SOGH and CH sites, but the necessary vacant pharmacist positions are not available at this time to make that change. #10 Red That the two 0.5 FTE Regional Pharmacy Manager positions should be increased to one 1.0 FTE position and one 0.75 FTE position. Note: The implementation of this recommendation would eventually require new funding for 0.75 FTE additional management position. Given Winnipeg Regional Health Authority, 2004 vii

10 that there is unlikely to be new funding available to the Regional Pharmacy Program in the immediate future from the ABC Project, the Pharmacy Project Team believes that this recommendation should be tabled until funding does become available. When funding becomes available to address the 45.2 FTE position shortfall in regional pharmacy staffing, this recommendation would then be revisited. #11 Green That the ratio of management to front-line staff be maintained at or below the national benchmark. Note: The overall number of site and regional pharmacy managers under the proposed new model (recommendations 9 and 10) would be approximately 18.0 FTEs. This would represent 5.1% of total pharmacy FTEs following the addition of the 45.2 FTEs required to bring the Regional Pharmacy Program staffing to mean benchmark staffing. That figure compares favorably to the national average of 5.4% for pharmacy management staff reported in the 2001/2002 Lilly hospital pharmacy survey. 3 #12 Green That pharmaceutical care coordinators not be a part of the management structure. The clinical leadership role envisioned for these positions is felt to be more appropriately included within the role of clinical leaders. The role of clinical leaders has been defined as part of the career ladder for pharmacists that has been developed by the Regional Pharmacy Program. Recruitment and Retention Applicable to All Pharmacy Regional Program Staff #13 Green That the following initiatives be implemented or maintained as a means of supporting the recruitment and retention of all pharmacy staff: Encourage the recruitment and retention of staff of aboriginal background. Maintain competitive wages. Provide flexible work hours. Implement initiatives to create a quality work life for all staff. Winnipeg Regional Health Authority, 2004 viii

11 Expand the role of the pharmacy technician. Develop a fair and equitable education plan for all regional pharmacy employees. Provide opportunities for, and reward participation in, advanced education programs. Provide adequate time to participate in projects, research, etc. Develop strategies to encourage women to increase their participation in the workforce and in the area of management (flexible hours, daycare, etc.) Ensure manageable workloads by increasing staff to the levels identified in the External Review. Provide career laddering opportunities for all staff. Acknowledge staff contributions, by providing appropriate reward and recognition opportunities. Address issues around inadequacy of workplaces, including problems with facilities and equipment. Improve the use of technology as a method of improving the quality of work life. Examples include Pyxis implementation, ability to access patient information, etc. Provide mechanisms to involve staff in decision-making. Develop a work culture that is friendly, team focused, and supportive. Provide adequate management support, as good leadership is essential for creating a work life conducive to recruitment and retention. Provide adequate resources to support student placements. Provide positive student experiences during their placement. #14 Red Provide a $250 educational allotment per employee per year as part of the Regional Pharmacy Program s budget. Education funds need to be managed as part of the Regional Pharmacy Program to ensure that the allocation of resources is in the best interests of the region. Applicable to Pharmacists #15 Green Continue to participate in job fairs, particularly those in Saskatchewan and Manitoba. Winnipeg Regional Health Authority, 2004 ix

12 #16 Green Consider the employment of foreign-trained pharmacists, on a case-by-case basis, if the candidate has a current license to practice in Manitoba or is immediately eligible for license to practice. #17 Red Continue with tuition relief/return of service agreements. Based on current projections, contracts would need to be available annually. #18 Green Continue to fund moving expenses for new pharmacist recruits. #19 Green Advocate for increased enrollment at the University of Manitoba. #20 Green Continue the WRHA hospital pharmacy residency program. #21 Red Increase pharmacy residency stipends to $40,000 per resident, in order to be competitive with other Canadian residency programs. #22 Green Develop a system to enable the sharing of clinical practice experiences and expertise across the region. #23 Green Provide a mentorship support system for pharmacists in the early stages of developing their clinical practice role. #24 Red Increase clinical time. The goal of the Regional Pharmacy Program is to achieve 60% clinical practice for all pharmacists. Winnipeg Regional Health Authority, 2004 x

13 #25 Yellow Implement a comprehensive regional vacancy management strategy to insure that there is an equitable distribution of pharmacist manpower within the region. #26 Yellow Enable the region to use pharmacists staffing budgets as a regional resource, so that staff can be deployed as required to manage pharmacist vacancies, support training of new staff from other sites, etc. Applicable to Pharmacy Technicians #27 Yellow Improve ability to provide relief coverage for technicians. The development of a casual pool may be beneficial. Drug Distribution #28 Green That funding for Pyxis and Cerner implementation at VGH remain as a high priority in the Regional Pharmacy Business Plan and proceed once funding is available. #29 Green That funding for Pyxis and Cerner implementation at GGH be included in the next Regional Pharmacy Program business plan, given that the GGH has recently made the decision to pursue Pyxis and Cerner implementation at that site. #30 Red That resources be made available to support expansion of IV admixture services at all sites. It is further recommended that the WRHA continue to explore opportunities to develop a centralized system for IV admixture. Winnipeg Regional Health Authority, 2004 xi

14 #31 Green Continue with the steps required to expand Tech Check Tech and pursue other opportunities for expanding the role of technicians. This would include advocacy, on the part of senior management, for enabling changes to the provincial pharmaceutical act. #32 Green That the need for an increased number of technicians, as well as increased educational resources to ensure adequate training and quality assurance programs, be given a high priority when ABC funding becomes available for reinvestment in pharmacy services. #33 Green That implementation of the regional pharmacy information system proceeds as funding becomes available. Priority should be given to the sites that currently have the oldest and least effective pharmacy information systems, i.e. VGH and GGH. Automation of the drug distribution systems (Pyxis) at those two sites is dependent on these upgrades. #34 Green That an automated dispensing/packaging system for the long-term care beds at the DLC and MHC be implemented, once funding becomes available. #35 Red That the WRHA support the implementation of centralized unit-dose packaging for acute care sites, by approving the request for equipment funding. A system that is able to support the entire region is the ideal. Procurement of a regional automated packaging machine is essential as the existing ATC-212 drug packaging systems will no longer be supported by the manufacturer after The machines will have to be replaced at GGH, SOGH, and VGH. Winnipeg Regional Health Authority, 2004 xii

15 Clinical Pharmacist Support #36 Red That the WRHA Regional Pharmacy Program strives to achieve Clinical Pharmacy Support Level 2 and Level 3, as described in this report and supports the further development and implementation of clinical practice standards. It is recommended that the WRHA support this initiative by providing increased levels of staffing and improved drug distribution systems outlined in Sections 4 and 6 of this report. #37 Red That sufficient pharmacist staffing, as identified in the External Review, be provided to support the clinical, decentralized role of the pharmacist. #38 Red That sufficient pharmacy technician staffing, as identified in the External Review, be provided to support the clinical, decentralized role of the pharmacist. #39 Green That implementation of the drug distribution systems described in Section 4 of this report, and implementation of a comprehensive regional pharmacy information system at all sites, be given a high priority in capital planning for the region. #40 Green That the Regional Pharmacy Program continue its efforts to improve access to relevant patient information and drug information at the point of care. #41 Green That the Regional Pharmacy Program be encouraged to continue with the development and implementation of the career ladder for pharmacists. Its use as a means of reward and recognition be further explored with Human Resources and the applicable collective bargaining units. The Regional Pharmacy Program will continue to pursue the development and refinement of the Pharmacy Clinical Leader position. Winnipeg Regional Health Authority, 2004 xiii

16 #42 Green That education and development programs for staff pharmacists be recognized as a necessary support for the successful implementation of the proposed career ladder. The creation of an educational support service within the WRHA s Regional Pharmacy Program, as proposed in the Program s Business Plan, is recommended. #43 Green That the Regional Pharmacy Program continues to pursue opportunities for extending clinical pharmacist support throughout the continuum of care. Adequate Pharmacy Staffing Levels #44 Green That agreement in principle is affirmed to increase pharmacy staffing to benchmark levels over the next five years, commensurate with availability of resources. #45 Green That the Steering Committee endorses the ABC Regional Pharmacy Model team s proposed plan to defer staffing allocation until funding becomes available. The Regional Pharmacy Program will then complete an in-depth assessment, analysis, and consultation when information regarding the availability and amount of funding for reinvestment is known. Once funding is secured, the Regional Pharmacy Management group will assess needs across the region, provide up to date recommendations, and proceed to implementation. Winnipeg Regional Health Authority, 2004 xiv

17 1. Introduction The Regional Pharmacy Model project was tasked with examining and refining the regional approach for pharmacy services and developing a plan for investments in pharmacy staff and services across the region. A major goal for the WRHA Regional Pharmacy Model is to provide an organizational structure that supports pharmacy initiatives. The focus is on medication safety and maximizing the clinical role of pharmacists so that patients derive full benefit of the pharmacists involvement in their care. In order to achieve these goals, pharmacy service infrastructure must be consistently in place at all facilities, including a robust pharmacy information system and a modern, safe, efficient and reliable drug distribution system that frees pharmacist time for clinical activities. Appropriate staffing levels are crucial to the success of the overall plan. Recruitment and retention strategies need ongoing support to achieve and maintain staffing to national benchmark levels. The achievement of these goals would result in desired clinical outcomes and improved quality of life for the patients that are served, as well as effective utilization of material (medications, technology, etc.) and human (nursing and pharmacy) resources. This report describes the work of the team and provides recommendations for achieving these goals. The report has been divided into sections to reflect the sub tasks that the project team addressed. It is essential that each section not be considered in isolation as the sections describe pieces of a comprehensive pharmacy program and all aspects must be considered as supportive of the overall service delivery model. Winnipeg Regional Health Authority,

18 2. Organizational Structure, Role, Authority, and Accountability This section of the report will focus on the phase of the ABC project related to Organizational Structure, Role, Authority, and Accountability for the Pharmacy Regional Program and the resources required to support a regionalized approach to Organizational Structure, Role, Authority, and Accountability. The External Review conducted by Deloitte and Touché identified that: There is a need to provide clear direction for the role and authority of the Regional Pharmacy Program team, as well as the roles and authority of the site pharmacy program teams. There is a need to reduce the barriers between the Regional Pharmacy Program and the site-based pharmacy programs through improved communications and reduced competition. There is the need for ongoing leadership and professional development of Regional Pharmacy Program teams. To help address these issues, one of the objectives given to the ABC Regional Pharmacy Project Team was to develop a regional pharmacy model to provide further support to a regionalized approach to the management and delivery of pharmacy services. This report addresses changes to the organizational structure, role, authority, and accountability of the Regional Pharmacy Program that the Project Team believes are necessary to achieve this objective. A. Organizational Structure, Role, Authority, and Accountability Overview With the regionalization of hospital-based health care services in 1998, the opportunity existed to not only address facility-specific needs, but also to realize the potential for a more effective and efficient Regional Pharmacy Program. It was envisioned that pharmacy services could be reorganized in such a way that it would be possible to exploit the opportunities that exist for sharing of resources, reducing duplication of effort, and standardizing pharmacy services within the Winnipeg hospital system. Winnipeg Regional Health Authority,

19 A Regional Pharmacy Model In 1998, when the WRHA s pharmacy services were first organized as a regional program, a new organizational model for pharmacy was created. Regional Pharmacy Managers Regional Pharmacy management positions were included in the model. It was expected that many of the responsibilities previously dealt with on a site-by-site basis could be handled more effectively by pharmacy managers who would be responsible for addressing these needs from a regional perspective. In addition to the positions of Regional Director and Administrative Director for the Regional Pharmacy Program the following Regional Pharmacy Manager positions were created: Drug Procurement and Inventory Control (1.0 FTE) Drug Distribution Systems and Investigational Drug Services (1.0 FTE) Drug Information/Drug Use Management (1.0 FTE) Pharmacy Information Systems (1.0 FTE) Educational Services (0.5 FTE) Professional Practice Development (0.5 FTE) Site-Specific Pharmacy Management Responsibilities With the regionalization of the responsibilities described above, it was envisioned that there would be a change in the scope of responsibilities required of Site Pharmacy Managers. In the model implemented in 1998, it was anticipated that the emphasis of these individuals responsibilities would be more on day-to-day operations than they would be on planning and development activities. Specific responsibilities would include: Day-to-day supervision of pharmacy operations Day-to-day human resource management Resolution of site-specific issues/problems that arise on a dayto-day basis Liaison with facility management Liaison with site-specific clinical program managers Winnipeg Regional Health Authority,

20 Liaison with other pharmacy managers responsible for regionwide initiatives Overseeing the collection and reporting of site-specific financial and operational data The complement of pharmacy directors/assistant directors/ coordinators at each of the WRHA facilities was reduced as outlined in the table below: Facility Site-Specific Pharmacy Management Staff 1998 WRH Site-Specific Pharmacy Management After Regionalization Net Change Seven Oaks Concordia Grace Victoria Deer Lodge Misericordia Riverview St. Boniface HSC * Total * * Did not include HSC Pharmacy Director's position that had already been deleted. Sites with 0.5 FTE site management positions were given the option of combining the management of two sites under a single shared Site Pharmacy Manager, or employing a Site Pharmacy Manager on a 0.5 FTE basis. Shared Site Pharmacy Manager positions were eventually agreed upon for the VGH/GGH sites, the CH/SOGH sites, and the DLC/MHC sites. Riverview opted to employ its own 0.5 FTE Site Pharmacy Manager. Winnipeg Regional Health Authority,

21 Pharmaceutical Care Coordinators Unlike most other allied health disciplines, it was recognized that a large portion of the pharmacy services delivered to the WRHA clinical programs would come from a centralized pharmacy department at each site that would simultaneously serve multiple clinical programs. It was therefore felt to be important that, in the absence of direct clinical program control of pharmacy resources, the Regional Pharmacy Program develop organizational links to the clinical programs as a means of insuring that the needs and concerns of the clinical programs would be addressed. In the planning discussions that had occurred, it had been suggested that these clinical service coordinators would be individuals who were actively involved in the provision of clinical services to a specific clinical program. Their job would be to serve as the liaison between the regional pharmacy service and the clinical programs. The management responsibilities of these clinical staff were anticipated to occupy only a small proportion of the coordinator s time, in comparison to their clinical responsibilities. In general, it was thought that the issues brought forward by these coordinators would be addressed by other pharmacy managers with site or regional management responsibilities. No back filling of clinical time was therefore anticipated to be necessary for the limited management responsibilities they would assume. These coordinator positions were not filled initially, but in 2001, on a two-year trial basis, two Pharmaceutical Care Coordinators were appointed as liaisons to the Medicine and Child Health Clinical Programs. A.2. Accountability Relationships within the Regional Pharmacy Program It was initially proposed that all pharmacy managers in the WRHA have a direct line of accountability to the Regional Director of Pharmacy. The Site Pharmacy Managers would also have a secondary accountability relationship to senior management at their site, and Pharmaceutical Care Coordinators would have a secondary accountability relationship to their clinical program. Following discussions with the site CEOs and Senior Management of the WRHA, a decision was made that Site Pharmacy Managers Winnipeg Regional Health Authority,

22 would have a dual reporting relationship to both their site and the Regional Pharmacy Program. Most sites have interpreted the model as being one where Site Pharmacy Managers have a direct accountability relationship to their site, and a secondary accountability relationship to the Regional Pharmacy Program. A.3. Issues Related to the Regional Pharmacy Management Model Looking back six years later, in 2004, the management model developed in 1998 has proven to have both its strengths and its weaknesses. Many accomplishments can be attributed to the model, including significant regional improvements and standardization of services in the portfolios managed by each of the Regional Pharmacy Managers. However, a number of modelrelated issues have been identified over the last six years. An external review of the Regional Pharmacy Program in 2001 (Wilgosh/Hunter Review 1 ) identified a number of these issues and provided recommendations for addressing these problems. Some of the recommendations were accepted and implemented while others, notably those that dealt with the reporting relationships within the Regional Pharmacy Program, were not implemented at that time. The major issues that the ABC Pharmacy Project Team has identified as ones that require action in order to address its mandate related to the organizational structure, role, authority, and accountability of the Regional Pharmacy Program can be summarized under the following headings: Accountability Relationships and Their Impact on the Timeliness and Quality of Decision-Making The current organizational structure and reporting relationships within the Regional Pharmacy Program work best when the Regional Pharmacy Program and all sites agree that a particular issue must be addressed collectively, and also agree on the course of action that must be taken to address the issue. The model has often not worked well in the face of disagreements in these areas, largely because of the absence of a shared accountability relationship. Some Site Pharmacy Managers have reserved the right to opt out of regional initiatives, either on the basis of their site s direction or their own personal judgment concerning the Winnipeg Regional Health Authority,

23 merits of a particular initiative. Most regional initiatives are not viable without the participation of all sites, so the need for unanimity has prevented or delayed a number of efforts to improve the way pharmacy services are managed. Even when these issues have ultimately been overcome, the lengthy time required to make decisions has resulted in missed opportunities, and allowed some problems to progress to crises. It can also be argued, as the Deloitte and Touché report suggested, that the need for unanimity has resulted in strategy dilution, since any changes must be perceived by all sites as being beneficial and relatively risk-free. The lack of clarity in the accountability relationships has also been detrimental to personal relationships within the Regional Pharmacy Program. On a number of occasions, disagreements within the Regional Pharmacy Program have been elevated to higher levels for dispute resolution. In that scenario there has usually been a winner and a loser, which does not contribute to the maintenance of a collaborative working relationship amongst the pharmacy managers. Budget Management Issues The Regional Pharmacy Program as a whole has consistently achieved a budget surplus at year-end. There have, however, been instances where a particular site pharmacy required additional resources in order to address a short-term problem. Although there were surpluses in other sites that could have been used to address the problem, the Regional Pharmacy Program was not able to utilize those resources to do so. There have also been situations where the Regional Pharmacy Program could have benefited from overspending at a particular point in the year, knowing that under spending would occur later in the year (e.g. over-hiring of pharmacists from the graduating class in the spring of the year, knowing that unfilled vacancies, and the associated accumulation of a surplus, could be anticipated by late fall of each year). The site-based management of pharmacy budgets, as part of their overall site budget management, has not allowed this to occur. The Regional Pharmacy Program has not been able to manage its budgets as a collective resource, in order to allow these types of actions to be taken. This creates significant obstacles to the Winnipeg Regional Health Authority,

24 implementation of regional on-call services, regionalization of drug information resources and services, centralization of repackaging functions, centralization of IV admixture services, etc. Staff Management Issues The Regional Pharmacy Program has not been able to manage its staff resources as a collective whole. This has negatively impacted on the ability of the Regional Pharmacy Program to manage a number of pharmacy manpower issues. It is also an obstacle to the sharing of educational resources, since the sites with experts do not see the benefit to their site of allowing time for those individuals to train and educate staff at other sites. This inability to manage staff as a regional resource will be particularly problematic when the Program is in a position to undertake changes such as the centralization of repackaging functions, the centralization of IV admixture services, and the regionalization of drug information services. Shared Site Pharmacy Manager Workloads The workload of the shared Site Pharmacy Managers has been a problematic issue. There are probably a number of reasons why this problem has persisted. It is possible that the original model did not adequately consider the extent of the pharmacy management responsibilities that would remain at each site. However, some other regions throughout the country have shared Site Pharmacy Manager positions that appear to be working, although the facilities they are managing are smaller than the sites being managed by the WRHA s shared Site Pharmacy Mangers. It is also possible that the success of the Regional Pharmacy Manager positions has created significant new workload for the Site Pharmacy Managers who are usually actively involved in the implementation of new regional pharmacy initiatives, related to the many changes that have been taking place. (See Appendix 3 Regional Pharmacy Managers Survey) Site expectations of the Site Pharmacy Managers also contribute to the workload demands. Many sites have not altered their expectation that their Site Pharmacy Manager be an active participant in the general management activities at each of their sites. This has led to a situation where Site Pharmacy Managers Winnipeg Regional Health Authority,

25 are expected to participate in all of the usual management meetings at each of their two sites, to receive and act upon all of the and site management requests at both of their sites, and to participate in social activities at each of their sites. Regardless of the relative contribution of each of these factors, it has become clear that the workload demands placed upon Site Pharmacy Managers must be addressed. This can either be achieved through a reduction in the workload demands, or by returning to a model where there is a full-time pharmacy manager at most of the WRHA sites. Part-Time Regional Pharmacy Manager Positions The part-time Regional Pharmacy Manager positions have also proven to be challenging for the incumbents. This has been particularly true of the Educational Services position. The demands of managing student placements, coordinating lecturing by regional pharmacy staff involved in teaching programs at the University, managing the training of new staff, and managing the pharmacy residency program have proven to be excessive. In the last two years the Regional Pharmacy Program has, in its section of the regional health plan, identified the need for a substantial increase in the human resources committed to the delivery of educational services within the WRHA. That plan has anticipated an increase in the position of Regional Pharmacy Manager-Educational Services from 0.5 FTE to 1.0 FTE. In the case of the Regional Pharmacy Manager - Professional Practice Development, the workload has also been challenging. However, the incumbent emphasized to the ABC Project Team that the maintenance of a clinical practice, at least on a part-time basis, was very important for this position. The Team concurred with his assessment. After further discussion it was agreed that an increase in the Regional Pharmacy Manager - Professional Practice Development from 0.5 FTE to 0.75 FTE would be recommended by the ABC Pharmacy Team. Winnipeg Regional Health Authority,

26 B. Benefits of Implementing Changes to the Organization, Role, Authority, and Accountability of the Regional Pharmacy Model The implementation of a more regionalized approach to the management and delivery of pharmacy services will result in a Regional Pharmacy Program that provides desired clinical outcomes, improved quality of life for patients, a high quality of work life for staff, and effective and efficient utilization of human and material resources. Benefits that would result from the implementation of the proposed model include: For Clients Patients and other caregivers are the ultimate beneficiary of pharmacy services. It is anticipated that a more effective and efficient organizational structure, resulting in improved accountability relationships, will facilitate the implementation of many of the regional pharmacy initiative that have been developed to help us achieve the Regional Pharmacy Program s Vision 2007 statement: By the year 2007, WRHA Regional Pharmacy Services will consist of: A comprehensive system of safe medication practices Pharmacy staffing and service levels that compare favourably to benchmarks for similar Canadian health care organizations A pharmacy practice model for the provision of patientoriented services (clinical pharmacy/pharmaceutical care), that is applied consistently throughout the region, across the continuum of care Appropriately-resourced, targeted ambulatory care pharmacy services Contemporary, state-of-the-art drug distribution systems Winnipeg Regional Health Authority,

27 A regional pharmacy information system, and other information technology systems, that support staff in their day to day activities and facilitate communication within and beyond the pharmacy program A drug use management system that ensures optimal, cost-effective use of drug therapies Efficient and effective pharmaceutical contracting, procurement, and inventory control systems An effective and accessible staff development program Which collectively will achieve: Desired clinical outcomes and improved quality of life for the patients that we serve A high quality of work life for staff of the Regional Pharmacy Program Effective and efficient utilization of human and material resources For Staff As stated in our Vision 2007 statement, the achievement of the objectives laid out for the Regional Pharmacy Program would be expected to result in a high quality of work life for staff of the Regional Pharmacy Program. The clarification of reporting relationships, common employment rules, and more consistent and timely management of labour issues are expected to facilitate achievement of this goal. Staff will also benefit from having a full time site manager available to provide leadership and support. For Sites It is recognized that the sites may have some concerns about the loss of direct control over their pharmacy managers, staff and budgets. However, it is felt that the sites will be in a better position to insist on greater consistency regarding the provision of pharmacy services across all sites. Sites will also benefit from improved management of pharmacy manpower resources, and from the achievement of the objectives laid out in the Vision 2007 statement, which are more likely to be achieved under the new pharmacy Winnipeg Regional Health Authority,

28 organizational structure. The sites with shared Site Pharmacy Managers will also benefit from the increased presence of the pharmacy manager at their site. For Clinical Programs The clinical programs would also benefit from the implementation of many of the regional pharmacy initiatives that have been developed to help us achieve our Vision 2007 statement. For the Regional Pharmacy Program The Regional Pharmacy Program would be much better positioned to achieve its Vision 2007 Statement and to move forward effectively into the future. The infusion of additional management resources would assist the Regional Pharmacy Program in developing and implementing a pharmacy management succession plan. For the WRHA The WRHA would benefit from the improved regional approach to provision of pharmacy services, more effective and efficient utilization of pharmacy resources, and more effective management of pharmacy manpower issues. C. Consultations with Stakeholders and ABC Team Methodology The ABC project team reviewed and discussed the current regional structure as well as conducting the following activities: a. Review of Relevant Resource Material (See Appendix 1: Resource List) b. Presentations by Other WRHA Regional Programs 1. Laboratory Medicine Program Keith McConnell 2. e-health Ian Fish Winnipeg Regional Health Authority,

29 c. Site/Regional Pharmacy Managers Survey (See Appendix 3: Regional Pharmacy Managers Survey) Surveyed management group to determine issues and workload items. Key Points Overall the survey indicated that the matrix reporting relationship was confusing and often frustrating for the site managers and that managing two sites frequently resulted in unrealistic demands. d. Survey of Major Canadian Health Regions (See Appendix 4: Regional Pharmacy Model Survey Results) Survey was designed to identify key elements inherent in a successful Regional Pharmacy Program. Key Points All surveyed regions reported that Pharmacy is structured as a Regional Program. All sites reported that pharmacy managers and staff report to the Regional Director of Pharmacy. With the exception of the Capital Health Region in Edmonton, the regions surveyed reported that all pharmacy staff are employed by the region. In Edmonton, staff within the Caritas group of hospitals are employed by the Caritas sites, not by the region. However, the day-to-day reporting relationships are aligned to the Regional Pharmacy Program. e. Presentations by Regional Managers and Site Managers Regional and site managers provided information regarding the key job responsibilities and identified aspects that were working well and areas requiring improvement. Key Points Site Pharmacy Managers identified that a single line of accountability would result in more effective and Winnipeg Regional Health Authority,

30 responsive management of pharmacy services and human resources. There was a desire for increased clarity around responsibility and accountability in regards to implementation of initiatives. The need to align the financial resources as well as the reporting relationship was identified. At the sites where there are shared Site Pharmacy Managers, Senior Pharmacists have been drawn away from their front-line clinical roles to provide management support, particularly when the Site Pharmacy Manager is off-site. The organizational structure should support a practice environment, which supports an enhanced clinical role for staff pharmacists. D. Recommendations Related to Organization, Role, Authority, and Accountability of the Regional Pharmacy Program The Project Team recommends: #1 Yellow That Site Pharmacy Managers be directly accountable to the Regional Director of Pharmacy and be employed by the WRHA. Site Pharmacy Managers would have day-to-day responsibility for ensuring that their particular site s pharmacy related needs were being met, and would have matrix reporting accountability to Site Senior Management with respect to established service expectations. #2 Yellow That the Regional Director of Pharmacy be responsible for the performance evaluation of Site Pharmacy Managers, with input requested from each site CEO/COO at the time of the performance appraisal. Winnipeg Regional Health Authority,