Model Standards of Practice for Canadian Pharmacists

Transcription

1 Model Standards of Practice for Canadian Pharmacists April 2003 National Association of Pharmacy Regulatory Authorities (NAPRA)

2 Publication supported by National Association of Pharmacy Regulatory Authorities, All rights reserved. No part of this document may be reproduced in any form by any photographic, electronic, mechanical or other means, or used in any information storage and retrieval system, without the written permission of the author. The National Association of Pharmacy Regulatory Authorities (NAPRA) 222 Somerset Street West, Suite 402 Ottawa, ON K2P 2G3 Tel: (613) Fax: (613)

3 Model Standards of Practice for Canadian Pharmacists Contents 4 Introduction 5 General Attributes Required of Pharmacists to Fulfil the Professional Competencies 6 Professional Competencies Required of Pharmacists 6 Professional Competency #1: Practise Pharmaceutical Care 15 Professional Competency #2: Provide Drug Information 19 Professional Competency #3: Educate 20 Professional Competency #4: Manage Drug Distribution 22 Professional Competency #5: Apply Management Principles 25 Optional Advanced Professional Competency #6: Undertake Research 26 References 27 Appendix A

4 Introduction The following Model Standards of Practice were developed by NAPRA s National Competency-Based Standards of Practice Working Group, a group of practising pharmacists from across Canada (see Appendix A). Members of the Working Group were selected from nominations submitted by provincial and territorial Pharmacy Regulatory Authorities (PRA) and national stakeholder organizations in response to a campaign to recruit skillful, proficient practising pharmacists with various numbers of years of experience, educational backgrounds, practice sites and geographical locations. This selection process was meant to ensure that the Working Group could develop realistic standards of practice that truly represented what all pharmacists must be able to do in community and hospital practice to ensure patient safety. The Working Group met in October 2001 after having discussed background information on competency-based standards of practice, NAPRA s Professional Competencies for Canadian Pharmacists at Entry to Practice (NAPRA, 1997)[1] and NAPRA s Model Standards of Practice for Canadian Pharmacists (NAPRA, 1998) [2]. Using these two documents as a starting point, a draft of the revised Model Standards of Practice was developed. Although the draft modifies the order and structure of the competencies from that listed in the original NAPRA documents, all competencies detailed within the Professional Competencies for Canadian Pharmacists at Entry to Practice are included. The primary change in these revised Standards limits the professional competencies to the roles or tasks performed by pharmacists as part of professional practice (e.g. providing pharmaceutical care, supervising drug distribution). These roles differ from the general attributes (e.g. knowledge and its application, communication, professionalism or ethics) that are necessary to fulfil the professional competencies [3]. Although the professional competencies and general attributes are defined separately, they are linked or integrated via performance indicators as described below. This approach has been used by a number of professions in Canada and in other jurisdictions [1, 3, 4, 5, 6, 7] and there is literature supporting such an approach to the development of Standards of Practice [3, 5, 6, 8]. In February 2002 a Consultation Paper containing Working Group recommendations was circulated to 28 stakeholders including the 12 provincial and territorial licensing bodies, provincial and national pharmacy advocacy organizations and national educational groups. The draft Model Standards were then revised based on the comments received from these reviewers. The final report of the Working Group was presented to the NAPRA Board of Directors in November Cognizant of the fact that regulatory authorities will adopt these standards, the Working Group attempted to ensure that the revised standards are realistic and will ensure patient safety. The standards are competency-based and define the levels of achievement required by pharmacists for competence in key areas of pharmacy practice [3]. Licensed pharmacists (those licensed for active practice) are expected to maintain their ability to perform the five competencies to the standards specified. Although national review indicated that the revised Model Standards were, in general, set at an appropriate level, several reviewers expressed concern that they represented a minimum level of expected performance. The Working Group agreed with this comment, but a key, literature-based decision had been made early in the development process that the revised Model Standards of Practice would define what all licensed pharmacists* must be able to do during daily practice to ensure patient safety. This use of a common minimum standard for all licensed pharmacists is consistent with other health professions and with the public protection mandate of NAPRA s Members [9]. The Working Group also recognized, however, that individual pharmacists and the profession as a whole aspire to continuously improve practice performance beyond the standard of what all pharmacists must do to ensure public safety. Therefore, to assist pharmacists in identifying areas for individual continuing professional development, the Working Group also identified a series of guidelines for advanced and / or exemplary practice. NAPRA offers these guidelines as benchmarks against which pharmacists might compare their own practice and performance when identifying strengths, weaknesses and areas for individual continuing professional development [10], [11]. Since the range of advanced roles for pharmacists is quite broad, no attempt was made to set exemplary practice guidelines for all potential roles. Focus was maintained on common roles assumed by experienced practising pharmacies. The inclusion of these advanced or exemplary guidelines aims to both encourage and reward continuing professional development by individual pharmacists. The following revised Model Standards of Practice for Canadian Pharmacists includes five components [3]: 1. a statement of the major professional responsibilities of the pharmacist ( i.e. competency units); 2. a description of the situations in which all pharmacists must be able to perform each competency; 3. the steps required to successfully fulfil each competency unit (i.e. competency elements); 4. the level of performance expected of all pharmacists for each competency element in order to be considered competent ( i.e. required performance indicators), and; 5. to further clarify these performance indicators, practical examples of specific pharmacist activities that could demonstrate the fulfilment of each required performance indicator. To be clear, it is not expected that pharmacists would perform each and every one of the examples of activities. These are included to facilitate the understanding of the practical, realistic nature of the requirements. Through the course of revising the Model Standards of Practice, a number of changes to the competency units and elements listed in NAPRA s Professional Competencies for Canadian Pharmacists at Entry to Practice were recommended. However, the NAPRA Board of Directors agreed with the Working Group s recommendation that the Professional Competencies not be revised at this time as these Competencies are currently being used by a number of provincial and national organizations. Instead, the Working Group provided all of the suggested revisions to NAPRA for future use by the National Advisory Committee on Licensing during their review of the Professional Competencies for Canadian Pharmacists at Entry to Practice (scheduled for 2005). Working Group members wish to thank all respondents, and emphasize that all comments received were reviewed and considered for inclusion in these final Model Standards of Practice. The Working Group also recognized that these Model Standards will be reviewed regularly and altered as practice responsibilities change and the profession evolves. * All pharmacists licensed in the active part of the Register in those jurisdictions with a two-part Register 4 Model Standards of Practice for Canadian Pharmacists

5 General Attributes Required of Pharmacists to Fulfil the Professional Competencies Knowledgeable Pharmacists must possess and be able to apply a broad, integrated knowledge of the core functional information associated with the profession of pharmacy. Such functional knowledge focuses on an understanding and ability to apply the information that is required during daily practice, and does not focus on detailed facts that are easily located in references (such as doses, costs of medications, trade names, names of management theories). The possession of such knowledge and the ability to apply this knowledge to solve problems and make appropriate decisions, is the base upon which competency as a pharmacist is built. Without knowledge and the ability to apply it, pharmacists will not be able to fulfil their professional responsibilities. Pharmacists must: have and be able to apply functional knowledge while solving problems and making decisions during completion of their professional responsibilities. This functional knowledge includes knowledge from the biomedical sciences (e.g. physiology, microbiology, pharmacology), the pharmaceutical sciences (e.g. medicinal chemistry, toxicology, pharmacokinetics and pharmacotherapeutics), the behavioural and social sciences (e.g. psychology, communications, ethics and illness behaviour), the administrative pharmacy sciences (e.g. pharmacy management and health care systems), and pharmacy practice (e.g. pharmaceutical care, compounding & dispensing, structured practical training). Professional Pharmacists must function professionally when fulfilling their responsibilities. Professionalism is defined as altruism, accountability, excellence, duty, integrity and respect for others, thereby incorporating the concepts of ethics, self-directed learning and professional identity [12]. Pharmacists must: consistently accept responsibility for actions and decisions. consistently demonstrate respect for others. consistently provide professional pharmacy care to individual patients that complies with the ethical guidelines governing the profession. maintain appropriate inter-professional relationships required to provide quality pharmacy care to individual patients. consistently provide care and services that place the best interest of patients before their own self-interest. continuously strive to improve professional competence through the use of appropriate learning to address areas identified for professional improvement / growth. consistently demonstrate personal and professional integrity. undertake non-pharmacy practice-related activities that are consistent with, and do not take advantage of the influence of, their status as a health professional. reject the acceptance of gifts / advantages that give the appearance of bias or conflict of interest. Proficient Communicator Pharmacists effectively use the communication skills required to fulfil each of the required professional competencies in the expected situations and to the level of performance specified. Pharmacists must: consistently demonstrate respect, sensitivity and empathy when communicating with others. consistently demonstrate appropriate verbal, non-verbal and listening skills. routinely demonstrate effective patient-interviewing techniques including: initiating a session, exploring problems, understanding the patient s perspective, structuring the discussion, building a patient relationship, facilitating the patient s involvement, explaining, planning, and closing the discussion [13]. consistently select and appropriately use communication techniques when communicating with peers, other health care providers, and staff. display effective writing skills. demonstrate comprehension and fluency in written and verbal English or French. Professional Competencies Required of Pharmacists: 1. Practise pharmaceutical care: Pharmacists in partnership with patients and other health care providers, use their unique knowledge and skills to meet patients drug related needs and to achieve positive patient outcomes by maintaining or improving the patient s quality of life. 2. Provide drug information: Pharmacists assume responsibility for information retrieval, evaluation and dissemination to ensure safe and effective provision of pharmaceutical care and to promote health. 3. Educate: Pharmacists educate individuals to support optimal patient care and to promote health. 4. Manage Drug Distribution: Pharmacists manage drug distribution by performing or supervising the functions of acquisition, preparation, and distribution of drugs to ensure the safety, accuracy and quality of supplied products. 5. Apply Management Principles: Pharmacists apply knowledge, principles and skills of management as they pertain to the site of pharmacy practice with the goal of optimising pharmaceutical care and professional relations. It is assumed that in fulfilling their responsibilities as pharmacists as defined by the standards of practice, all activities will be performed in accordance with relevant federal, provincial and territorial legislation, and regulatory authority policies and by-laws regarding the practice of pharmacy. Model Standards of Practice for Canadian Pharmacists 5

6 Professional Competency #1: Practise Pharmaceutical Care Competency unit Pharmacists in partnership with patients and other health care providers, use their unique knowledge and skills to meet patients drug related needs and to achieve positive patient outcomes by maintaining or improving the patient's quality of life. Situations in Which All Registered Pharmacists Must Fulfil this Competency: Pharmacists ensure that all patients have access to the care required to address their drug related needs. This means that: for patients with actual needs or potential problems related to drugs that are routinely used to manage common 1 diseases, and for those presenting common ethical or communication challenges, pharmacists possess the functional knowledge and skills required to provide pharmaceutical care and may use resources to confirm detailed or specific disease or drug information. for patients with actual needs or potential problems related to drugs that are used infrequently to treat common diseases, or drugs used to treat uncommon diseases, or uncommon or complicated ethical or communication challenges, pharmacists may consult with other pharmacists or health care providers and may use resources to acquire or review necessary drug, disease or other information. for patients with drug related needs or problems that are the responsibility, or within the scope of practice, of other health care providers, pharmacists refer for management; and for all patients, pharmacists provide medications and/or pharmacy services Pharmacists provide this care and these services to patients who desire the pharmacist s participation in their care and who are willing and able to accept the responsibilities required by this care. Pharmacists fulfil this competency in all sites where they provide the products and/or services that legally constitute pharmacy practice. Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.1 A pharmacist must develop a professional relationship with the patient. Offer all patients the opportunity to engage in a professional relationship by consistently demonstrating him/herself to be a caring health care professional. Effectively use interpersonal skills to overcome common challenges to communication. The pharmacist is available and makes time to answer patient s questions; provides privacy for patients who desire and/or require it; offers professional assistance in selecting non-prescription drug therapy & natural health products; presents a professional appearance; respects a patient s dignity, education, culture, beliefs, interests and desires; shows unbiased behaviours regarding, for example, race, religion, sex, language, and age of patients. The pharmacist speaks at an appropriate level to children or cognitively impaired patients; summarizes frequently to clarify information and facilitate discussion with poor historians; minimizes the use of jargon; calms anxious patients; pacifies angry patients. Clearly establish the normally accepted roles and responsibilities of him/herself and of the patient, including explaining their common goal of ensuring that the patient appropriately takes the right drug in the correct dose and dosage form, on the best schedule, for the appropriate duration of therapy and that side effects and / or lack of efficacy are identified and managed appropriately The pharmacist introduces self and explains that (s)he is here to teach the patient how to use a medication appropriately; requests patients to call the pharmacist if they have side effects or questions. Optional Performance Indicator reflecting Consistently develop professional relationships with patients who demonstrate uncommon or extreme challenges. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist overcomes uncommon communication challenges (illiterate, deaf, mentally-handicapped, foreign-language only, combative patients); manages ethical dilemmas; convinces reluctant patients of the value of a professional relationship with pharmacists and develops such relationships. 1. The term common is used throughout this document in its pragmatic sense to focus on issues that are frequently occurring rather than infrequent or obscure. No attempts have been made to define common diseases or drugs as these will change over time. 6 Model Standards of Practice for Canadian Pharmacists

7 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.2 A pharmacist must gather patient information and assess its relevance to patient care. Routinely use appropriate communication skills to obtain a clear understanding of the patient s perceived needs or questions. Routinely collect the information necessary to address the patient s drug related needs or questions, such as: when not obvious, the condition, symptoms or signs to be treated and / or the patient s self diagnosis the practitioner s diagnosis the seriousness of symptoms, particularly when addressing problems associated with self care / non-prescription drugs the patient s desired outcomes (implied or explicitly stated) relevant patient demographics relevant family medical history relevant social history (e.g. alcohol or nicotine use) the existence of relevant medical conditions the history of current condition, particularly when addressing problems associated with self care / non-prescription drugs known patient risk factors for adverse drug reactions, drug allergies or sensitivities known contraindications to prescription and nonprescription drug use relevant dietary restrictions other medications or treatments that the patient has tried for this condition and effects, particularly when addressing problems associated with self care / non-prescription drugs other medications or treatments that the patient is currently taking that may affect the condition or interact with therapy Routinely acquire the information necessary to determine if the patient s needs / problems fall beyond the domain or scope of pharmacy practice. Collect information in an effective, professional manner. Optional Performance Indicators reflecting Routinely collect the required information in an efficient manner while maintaining a professional, caring relationship with a patient. The pharmacist asks if the patient is having any problems with or questions about their medications; listens attentively to patient s questions / complaints; asks clarifying questions to ensure understanding of the patient s concerns. The pharmacist inquires about the severity and duration of diarrhea in an infant; asks about previous use of antihistamines when recommending management for seasonal allergies; asks the age and weight of a child; checks the patient s profile for previous use of antibiotics and reactions; contacts the physician to clarify the diagnosis when a dosage does not match the indication explained by the patient; asks the patient or checks his profile for additional therapies for hypertension; reviews phenytoin levels for prevention of toxicity; checks patient s serum creatinine when reviewing aminoglycoside dosing. The pharmacist reviews the profile of a patient who has had multiple high BP readings on several different days to see if he is taking an antihypertensive; asks a patient requesting throat lozenges if she has fever in addition to a very sore throat; asks a patient with tooth pain and fever if he has seen a dentist. The pharmacist reviews patient profiles for medication histories of prescription drugs; asks only relevant questions that provide necessary information; seeks information about a patient s health only when it is required to provide care to, or appropriately refer, the patient. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist uses a mixture of questioning techniques to limit excessive, unrelated discussion. Maintain an accurate knowledge of the availability of, and services offered by, health organizations and health care professionals within the community, including alternative health care providers. The pharmacist maintains knowledge about services available to seniors such as Meals on Wheels, social groups, transportation services, home care; knows of availability of physiotherapists, nutritionists, acupuncture practitioners; links patients with disease based organizations that provide information for public. Model Standards of Practice for Canadian Pharmacists 7

8 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.3 A pharmacist must identify a patient s desired therapeutic outcomes. Effectively establish realistic therapeutic outcomes consistent with the patient s desires. Correctly identify when no confirmation of desired outcomes is necessary. The pharmacist explains to the patient that there is no cure for the common cold but that products are available to relieve symptoms; explains to the patient that many antidepressants take 4-6 weeks before their best effects are seen; explains to the medical team that gum hyperplasia will not resolve with continued use of phenytoin. The pharmacist presumes that a patient with pneumonia wants it cured; presumes that a patient receiving aminoglycosides wants a therapeutic / non-toxic dose. Optional Performance Indicator reflecting Routinely inform long term clients of new therapies that offer similar or enhanced therapeutic outcomes Example of an activity that might prove fulfilment of Optional Performance Indicator: The pharmacist informs female patients of availability of bisphosphonates as an alternative to hormone replacement therapy for post-menopausal osteoporosis prevention 1.4 A pharmacist must identify a patient s actual and potential drug related problems. Effectively review every patient s profile to identify actual and potential drug related problems prior to dispensing a prescription, including the types of drug related problems listed below 3.. Effectively use the information collected in 1.2 and 1.3 above to identify a patient s actual and potential drug related problems, including the types of drug related problems listed below 3.. Untreated / continuing signs or symptoms For example: lack of bisphosphonate for a patient on chronic prednisone therapy; lack of aspirin therapy for a patient following a myocardial infarction; persistent fever in a patient taking amoxicillin for pneumonia (plus see examples requiring referral, 1.6) Contraindications for drug use For example: amoxicillin for a patient with a documented penicillin allergy. Drug interactions For example: treatment with erythromycin when taking theophylline; treatment with ibuprofen for a patient with a history of gastric ulcers; the use of cotrimoxazole for a patient on warfarin. Inappropriate doses, or signs / symptoms of toxicity or sub-therapeutic treatment For example: acetaminophen 1000 mg q4h for more than several days; blurred vision with digoxin; increasing frequency of seizures while on carbamazipine. Side effects For example: diarrhea during treatment with amoxicillin; GI bleeding with NSAIDs; rash with cotrimoxazole. Non-compliance For example: lack of understanding of the need to finish a course of antibiotics; failure to remove nitroglycerin patch for appropriate period each day to prevent tolerance; as necessary use of steroid inhalers rather than scheduled, regular use. Drug use for no valid indication For example: inappropriate use of dimenhydrinate; excessive use of narcotics, sedatives or hypnotics; use of diuretics for weight loss. 3. The types of drug related problems that pharmacists must be able to identify independently and without the extensive use of resources, versus those for which consultation can be used, are specified in the range statements at the beginning of the competency. 8 Model Standards of Practice for Canadian Pharmacists

9 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.4 (Continued) Routinely use resources and / or consultation to facilitate the timely identification of less common drug related problems. Effectively explain the mechanism / cause of a patient s drug related problem(s). Prioritize patient s drug related problems accurately. Optional Performance Indicators reflecting Complete full medication reviews to identify multiple drug related problems. The pharmacist uses the Internet to rapidly locate drug information; contacts the cancer treatment centre to ask about new chemotherapy dosing guidelines; contacts the pharmaceutical company for information on potential interactions; discusses availability of special compounding with specialist pharmacist The pharmacist uses the appropriate terminology to explain why a penicillin should not be used by a patient with a documented penicillin allergy or why nitroglycerin patches should be removed for a period of time each day. The pharmacist considers patient preference, medical significance and urgency; recognizes drug related problems that the patient believes are important; recognizes urgent or severe drug related problems that the patient or other health care providers want to ignore and educates them about the importance of these problems; recognizes drug related problems that are less critical or which do not require management. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist schedules patient appointments to complete work-ups of drug therapy; creates comprehensive patient records to facilitate identification of drug related problems; uses a systematic approach to identifying multiple drug related problems. Accurately and efficiently identify multiple, complex drug related problems based on extensive knowledge base and experience. The pharmacist immediately recognizes and confirms drug related problems based on extensive experience and is able to explain the therapeutics / pharmacology / pathophysiology underlying the drug related problem. 1.5 A pharmacist must develop therapeutic plans, recommending therapeutic options, doses, scheduling / administration, required drug devices and compliance aids. Maintain and utilize an efficient network of resources to facilitate identification of less common drug related problems. Routinely recommend appropriate non-drug therapy in addition or as an alternative to, drug therapy. When requested by a patient, provide accurate information concerning efficacy, toxicity, side effects or interactions of natural health products. Routinely recommend the use of appropriate drug devices to ensure effective drug use. The pharmacist maintains contacts with physicians, pharmacists, industry and specialist treatment centres to quickly obtain information required to identify complex or uncommon drug related problems. The pharmacist recommends the use of ice for a sprained ankle in addition to NSAIDs; suggests the use of a humidifier in addition to a topical decongestant. The pharmacist provides information on echinacea for management of colds; provides information on valerian for insomnia. The pharmacist recommends the use of aerochambers for children or infants using inhalers. Routinely develop and/or recommend the use of appropriate tools and products to aid in patient compliance. The pharmacist develops written summaries of daily medication requirements; recommends the use of dosing reminder aids (e.g. Dosettes ); recommends the use of specialty lids to facilitate opening of vials; provides medication counselling cards. Model Standards of Practice for Canadian Pharmacists 9

10 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.5 (Continued) Consistently recommend therapeutic options that are compatible with the patient s desired outcomes, rational and cost effective. The pharmacist, if appropriate, recommends nitroglycerin paste rather than nitroglycerin patches for a patient concerned about the cost of the patches. Effectively manage routine conflicts between ideal patient care and relevant health system policy. Effectively consult with a patient s other health care providers regarding the patient s therapeutic plan. Effectively justify his/her therapeutic recommendation. Routinely provide continuing pharmacy care and services to a patient who has refused a recommended change in drug therapy. The pharmacist contacts the physician for a change in prescription when financial problems would prevent the patient from taking a required medication. The pharmacist contacts a patient s physician to manage his/her drug related problem; obtains refill authorizations as necessary; obtains changes in prescription drugs as necessary; releases patient information only when necessary to provide continuity of care to that patient. The pharmacist explains the therapeutic rationale for recommendations (e.g. pathophysiology or cause of disease and mechanism of action of drug); provides any references used to develop a recommendation. Optional Performance Indicators reflecting Consider emerging, appropriate therapeutic alternatives when selecting therapeutic options. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist maintains and uses knowledge of current research and new drug therapies. Efficiently develop accurate therapeutic plans based on extensive knowledge base and patient experience. The pharmacist immediately knows appropriate therapeutic recommendations based on extensive experience and knowledge and is able to justify the recommendation. Efficiently develop therapeutic plans for complex, specialized drug related problems based on extensive knowledge base and experience in a specialized field of practice 1.6 A pharmacist must refer patients to other health care providers when required. Accurately and efficiently identify patients with signs/symptoms of potential medical emergencies and recommend they seek immediate medical attention. Accurately identify when patients problems are beyond the scope of pharmacy practice and refer them as appropriate to their family physician, dentist, optometrist, physiotherapist, nutritionist or social worker. Accurately address patients inquiries about the need to contact their physician if they are experiencing signs or symptoms associated with common diseases addressed in health promotion campaigns. The pharmacist recognizes the urgency of vomiting, diarrhea, fever and lethargy in an infant; severe, unrelenting headache in a patient with no history of migraines; unrelenting chest pain; palpitations in a patient taking high doses of theophylline. The pharmacist refers seniors having problems maintaining activities of daily living; patients complaining of chronic back pain; consistently elevated BP readings from pharmacy automated BP machine in a patient not taking antihypertensives. The pharmacist supports a patient s decision to see his/her physician about a breast lump or excessive thirst and urination. 10 Model Standards of Practice for Canadian Pharmacists

11 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.6 (Continued) Accurately identify patients whose self-diagnosis appears questionable and refer them as appropriate to their primary care practitioner. Accurately identify patients whose self-care treatment has failed to remedy a condition within the expected time frame and recommend that they contact their primary care practitioner. Offer accurate information to patients about the role of family physicians, dentists, optometrists, physiotherapists, nutritionists and social workers. The pharmacist refers a patient requesting more decongestant nasal spray for congestion with purulent discharge that has worsened over the last two weeks; refers a diabetic patient requesting a topical antibiotic cream for an infected cut on foot; refers a patient requesting NSAIDs for swelling and pain around a tooth. The pharmacist refers a patient with continued constipation with no bowel movements despite one week s treatment with psyllium. The pharmacist provides information about the role of nutritionists in the management of diabetes; explains the difference between optometrists and opticians. Optional Performance Indicators reflecting Routinely refer patients to appropriate health organizations and health care professionals within the community, including complementary and alternative health care providers. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist refers seniors to Meals on Wheels, social groups, transportation services, home care; refers patients to support or education groups; refers patients to appropriate acupuncture practitioners. Develop and routinely utilize referral systems The pharmacist routinely writes referral notes for patients to take with them to their physician; maintains professional contacts and relationships with a variety of health care providers and service providers available within the community. 1.7 A pharmacist must develop, implement and fulfil plans to monitor the patient s progress towards desired therapeutic outcomes Routinely and accurately identify the amount and type of education desired / required by patients to maximize their chances of solving or preventing their drug related problem(s). Routinely and accurately identify the degree of monitoring required by a patient according to the health risks posed by the patient s medication, drug related problem, or disease. The pharmacist recognizes that minimal information is necessary for a patient taking chronic medication and no new complaints; recognizes that a patient experiencing a migraine requires minimal immediate counselling (and additional information at a later point); identifies that a patient beginning hormone replacement therapy requires education on short term benefits relative to long term risks; recognizes that a patient with severe asthma requires occasional review of inhaler-use instructions. The pharmacist identifies that a patient with a history of non-compliance with antibiotics may require a follow-up telephone call when prescribed erythromycin for 10 days; recognizes that a patient controlled on chronic antihypertensive medication and no new complaints requires minimal monitoring; identifies that a patient taking long term tamoxifen for breast cancer should be asked about side effects and compliance on a regular basis; identifies that a patient being started on warfarin requires frequent monitoring during the stabilization phase; identifies that a patient on an aminoglycoside requires monitoring of renal function and possibly aminoglycoside levels; recognizes that a patient admitted with acute renal failure may need frequent dosage adjustment of their drug therapy. Model Standards of Practice for Canadian Pharmacists 11

12 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.7 (Continued) Routinely, effectively and, in consideration of the above two statements, appropriately educate patients on the following when dispensing prescription and non-prescription drugs, when patient counselling on discharge medications or when providing recommendations about management of specific drug related problems: name and class of the drug (e.g. antibiotic, pain reliever) directions for use including education about drug devices special storage requirements common or important drug-drug or drug-food interactions the reason for the drug 4 and the intended therapeutic response and associated time frames common or important side effects and associated time frames what the patient should do to monitor his/her therapeutic response or development of side effects actions the patient should take if the intended therapeutic response is not obtained or side effects develop when appropriate, the actions the pharmacist will undertake to monitor the patient s progress Consistently fulfil responsibilities for monitoring patients. Consistently communicate with covering pharmacists to inform them of individual patient needs for monitoring. Analyze monitoring data obtained to determine the success of the therapeutic plan or the development of new drug related problems. Communicate with patients care providers as necessary regarding the results of patient monitoring. The pharmacist discusses the use of metoprolol for prevention of a second myocardial infarction versus the lowering of blood pressure; that the frequency and pain on urination should resolve within 24 hours of starting amoxicillin for a urinary tract infection. The pharmacist discusses diarrhea that could start after the end of treatment with clindamycin; transient headache that may develop at the start of therapy with nifedipine. The pharmacist recommends that a patient keep a diary of headache times, intensity and duration. The pharmacist asks the patient to call if her constipation is not relieved in three days; recommends that the patient contact his physician if his fever has not resolved in three days; asks the patient to contact the pharmacist or physician if he develops diarrhea while taking or within two weeks after completing the treatment with clindamycin. The pharmacist asks the patient if (s)he would like the pharmacist to call a week after starting antibiotics. The pharmacist completes required patient contacts (as above) on the schedule agreed upon. The pharmacist leaves a summary of patients who should be contacted during the next shift, the reason for the contact and the expected outcome. The pharmacist compares patient s status to desired outcomes; ensures continued care if new drug related problems are identified. The pharmacist contacts patient s physician if the patient experiences persistent cough after starting an ACE inhibitor 4. It is recognized that pharmacists do not always have access to the therapeutic indication for the drug. 12 Model Standards of Practice for Canadian Pharmacists

13 Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 1.7 (Continued) Optional Performance Indicators reflecting Consistently use appropriate techniques to gain acceptance of the therapeutic and monitoring plans by relevant parties. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist uses extensive knowledge to support recommendations to patients or other health care providers; facilitates monitoring by developing simple, yet effective, monitoring plans. Create systems that facilitate patient monitoring The pharmacist uses software available to create call back lists; uses forms that specify normal monitoring parameters and time frames; uses a system for documenting therapeutic and monitoring plans; employs a follow-up appointment protocol as part of a disease management program; uses a liaison system between hospital and community pharmacies to ensure seamless care. 1.8 A pharmacist must document information. Consistently identify situations that require documentation to promote patient safety and / or to meet legal requirements. Document the above information in a usable, retrievable, timely manner. The pharmacist identifies the need to document the existence of allergies; previous serious adverse drug reactions or interactions; commitments to complete followup contact with patients at a specific time; changes in a prescription made to prevent a drug related problem (e.g. changes in dose, changes in drug to one covered by insurance; changes in drug to one with fewer side effects); the refusal of a physician to change a prescription; the refusal of a patient to allow contact with his/her physician. The pharmacist writes on prescription that patient has been counselled; enters allergies into patient profiles; notes on prescription or in profile that doctor was called to change the prescription and why; documents subtherapeutic phenytoin levels and dosing recommendations in a hospitalized patient s chart; documents clarifications of drug allergies or medications prior to admission. Optional Performance Indicators reflecting Document efficiently. Examples of activities that might prove fulfilment of Optional Performance Indicator: The pharmacist completes required documentation in succinct, complete, timely fashion, including only necessary information; consistently uses a specific documentation protocol or format (e.g. SOAP) for consistency and ease of retrieval. Develop and routinely using a system to document the provision of pharmaceutical care and patient outcomes. The pharmacist obtains approval to insert a pharmacy section in patient charts; develops software to record patient care and outcomes Model Standards of Practice for Canadian Pharmacists 13

14 Optional Advanced Roles: Possible Performance Indicators Examples of activities that might prove fulfilment of Possible Performance Indicators Drug Therapy/Patient Care Disease State Specialization Routinely initiate specific activities to identify patients with actual or potential drug related problems. Consistently complete full medication reviews, or assessments with patients to identify their multiple drug related problems. Accurately and efficiently identify multiple, complex drug related problems based on extensive knowledge base. Efficiently develop accurate therapeutic plans based on extensive knowledge base and patient experience. Routinely initiate follow-up contact with patients to monitor their progress towards predetermined outcomes. Routinely and efficiently document the provision of care and patient outcomes. Routinely summarize data on patient management to ensure continuity of care and to document the value of pharmacy services. Accept referrals of patients for management of drug related problems related to specific disease states. Complete focussed medication reviews to identify drug related problems in patients with specific disease states. Accurately and efficiently identify multiple, complex drug related problems based on extensive knowledge base in a specialty area of practice. Maintain and utilize an efficient network of resources in a specialty area of practice to facilitate identification of drug related problems. Efficiently develop therapeutic plans for complex, specialized drug related problems based on extensive knowledge base and experience in a specialized field of practice. The pharmacist offers brown bag sessions; offers education sessions on new drugs to identify patients at risk for drug related problems; completes home visits. The pharmacist schedules patient appointments to complete work-ups of drug therapy; creates comprehensive patient records to facilitate identification of drug related problems; uses a systematic approach to identifying multiple drug related problems. The pharmacist immediately recognizes and confirms complex, multiple drug related problems based on extensive experience and is able to explain the therapeutics / pharmacology / physiology underlying the drug related problem. The pharmacist immediately knows appropriate therapeutic recommendations based on extensive experience and knowledge and is able to explain the therapeutics / pharmacology / pathophysiology underlying the drug related problem to justify the recommendation The pharmacist schedules follow-up appointments at pharmacy; completes regular rounds on hospital patients; reserves specific time each week to contact patients for follow-up by telephone. The pharmacist participates in clinic days for specific diseases in order to identify patients who require more intensive review; schedules patient appointments to complete work-ups of drug therapy; creates comprehensive patient records to facilitate identification of drug related problems; uses a systematic approach to identifying multiple complex The pharmacist immediately recognizes and confirms complex, multiple drug related problems based on extensive experience in a specialty area and is able to explain the therapeutics / pharmacology / pathophysiology underlying the drug related problem. The pharmacist maintains contacts with physicians, pharmacists, specialist treatment centres and industry to quickly obtain information required to identify drug related problems in a specific disease or practise area. 14 Model Standards of Practice for Canadian Pharmacists

15 Optional Advanced Role: Possible Performance Indicators Examples of activities that might prove fulfilment of Possible Performance Indicators Disease State Specialization (continued) Establish and utilize systems to efficiently implement therapeutic and monitoring plans. Encourage the appropriate management of specific disease states by relevant health care professionals. Routinely and efficiently document the provision of care and patient outcomes. Routinely summarise data on patient management to provide continuity of care and to document the value of pharmacy services. The pharmacist manages drug treatment according to disease state guidelines; accepts appropriate and lawful responsibility for delegated medical acts; obtains required training / certification for actions required for disease state monitoring (such as diabetic counselling, blood pressure monitoring, asthma monitoring); establishes a follow-up appointment protocol as part of a disease management program; creates or leads support groups for clients with specific disease states. The pharmacist develops and uses systems to provide physicians with information to ensure appropriate prescribing according to evidence-based principles. Professional Competency #2: Provide Drug Information Competency Unit Pharmacists assume responsibility for information retrieval, evaluation and dissemination to ensure safe and effective provision of pharmaceutical care and to promote health. Situations in Which All Registered Pharmacists Must Fulfil this Competency 5 : In response to requests from individual patients or individual health care professionals, pharmacists provide: information about all drugs, including herbal therapies; recommendations concerning commonly used drugs in the management of common diseases, and; information about commonly recommended, evidence-based disease prevention and health promotion strategies. Pharmacists use appropriate, readily accessible secondary and tertiary 6 medical and pharmaceutical resources, Internet-based information and / or consultation with other pharmacists or health care professionals when fulfilling this competency. Pharmacists fulfil this competency in all sites where they provide the products and services that legally constitute pharmacy practice, or where they are identified as pharmacists when providing such information or recommendations. Competency Element Required Performance Indicators Examples of activities that might prove fulfilment of Required Performance Indicators 2.1 A pharmacist must identify sources of relevant information. Accurately determine the depth of information required to answer a question. Accurately identify whether tertiary, secondary or primary literature is necessary to appropriately respond to the request for information or recommendations. The pharmacist accurately differentiates between a physician s request for a standard dose of an antibiotic and a physician s request for recent changes in the treatment of choice for otitis media; differentiates between a patient s and a physician s question as to how Zyban works in the treatment of smoking cessation. The pharmacist differentiates between a patient s request for information on new antibiotics for treating urinary tract infections and a physician s request for information on investigational antibiotics for managing chronic urinary tract infections. 5. This competency differs from the provision of information to individual patients as part of patient counselling during the provision of pharmaceutical care (Competency #1). It also differes from Competency #3 which relates to the education of students or groups regarding drugs, drug use and health promotion. 6. Although pharmacists are encouraged to use primary literature, they must, at a minimum, use appropriate secondary and tertiary literature. Model Standards of Practice for Canadian Pharmacists 15