An iconoclastic perspective on progress in pharmacy practice.

Progress in pharmacy practice is examined and areas for improvement are identified. Data from surveys of hospital and health system pharmacy practice from 1957 to 1994 show that the steady progress from 1974 to 1985 was not sustained over the past decade. Changing to a profession in which all practitioners provide pharmaceutical care will be difficult when practice in hospitals, where the most acutely ill patients are treated, does not meet the profession's recommended standards. Many pharmacists may be resigned to a reality in which their services are viewed as ancillary. The number of medication misadventures that occur indicates that there is an unmet need for effective medication management. Pharmaceutical care offers the promise of better patient outcomes as well as "reprofessionalization" of pharmacists. To elevate the level of pharmacy practice, individual practitioners need will; too much attention has been given to skill. Many new practitioners have earned Pharm. D. degrees but not received enough nurturing from colleagues to develop into innovators who will continue the profession's progress. It is crucial that the pharmacy practice and education communities cooperate to prepare pharmacists to function in the changing health care system. Also, professional organizations must set aside their fragmented interests and focus together on pharmacists' survival. The restructuring and economic pressures in health care may offer pharmacists the opportunity for progress, since improving drug use would help to decrease health problems and cost.

Residency training--the profession's forge for leadership development.

The concept of leadership may be the most widely studied and least understood topic in the domain of social services. Leadership has been described as a major force in the profession's transition to pharmaceutical care and effective program development. Pharmacy practice residency programs are a major means of developing and sustaining leadership for the growth of the profession. Three concepts that are explored include: (1) some insight into noncognitive elements of residency training that are critical to the development of professional practice, (2) analysis of leadership perceived to be critical for pharmacists, and (3) a definition of how residency training can develop professional leaders to meet the challenges for pharmacy.

Pharmaceutical care: new management and leadership imperatives.

The management imperatives for pharmaceutical care concern themselves with complexity, while leadership imperatives are concerned with effecting change. Both "species" of action are needed to support the paradigm shift associated with pharmaceutical care. Pharmacy managers must be the architects and engineers of the new dimensions of complexity associated with pharmaceutical care while also serving as zealots of change for pharmaceutical care within their departments and hospitals. In the final analysis, departments of pharmacy do not practice pharmaceutical care. They are, however, the borne fruit of pharmacy managers and leaders who provide for an appropriate environment inclusive of resources and systems necessary for individual pharmacists to make the commitment to making pharmaceutical care a reality.

Louis Gdalman, pioneer in hospital pharmacy poison information services.

The role played by hospital pharmacist Louis Gdalman in the development of poisoning information services in the Chicago area is described. In the 1930s, decades before the creation of the Chicago Poisoning Control Program, Louis Gdalman had already established a poison information service at St. Luke's Hospital in Chicago. Pharmacists provided poison information to the physicians and nurses working in the emergency room. By the early 1950s, Gdalman had established an extensive library of information on the management of acute and chronic poisoning and had developed a standard form for the collection of data from poison information calls. He personally provided a 24-hour poison information service and often took calls at home. In 1953, the American Academy of Pediatrics initiated the Chicago Area Poisoning Control Program and established treatment and referral centers at 11 hospitals, including St. Luke's Hospital. Louis Gdalman was the only pharmacist involved in this city-wide program. By 1962, the Master Poison Control Center was established at St. Luke's Hospital, which had merged with Presbyterian Hospital in 1956. Today, this center, known as the Chicago and Northeastern Illinois Regional Poison Control Center, is located at the Rush-Presbyterian-St. Luke's Medical Center in Chicago. Louis Gdalman, a hospital pharmacist, pioneered the area of poison information and established what was perhaps the first hospital-based comprehensive poison control center.

P & T Committee rises to challenges of the changing healthcare environment.

The ever-increasing importance of the P & T Committee is well illustrated in this exclusive interview with members of a committee from a leading academic, private-practice, health-science center--Rush-Presbyterian-St. Luke's Medical Center. The participants detail the progress achieved in P & T Committee policy making, particularly in recent years. Unprecedented change in the healthcare environment has demanded a more aggressive P & T Committee, and theirs has responded appropriately. Because the medical staff at Rush constitute a unique blend of academicians and private practitioners, the mechanics of their decision making tends to be consensus-related, while the implementation of those decisions is education-oriented. Other P & T Committees can learn from their political and professional strategies in the management of drug therapy.

Management diplomacy: myths and methods.

The importance of a manager's ability to tolerate and overcome ambiguity is discussed in relation to achieving excellence in hospital pharmacy management. Health-care programming and policy in the 1980s are shaped largely by financing and increased corporate control; in this environment, hospital pharmacy managers face new definitions of excellence in management. Today's director of pharmacy must be "bilingual" in a sense, since he or she must effectively relate to the hospital's corporate administration on the one hand and the professional staff and patients on the other. The hallmark of excellence in a modern director of pharmacy is the ability to tolerate and overcome ambiguity that arises from both of these sources. Ambiguity may be rooted in issues external to the pharmacy department, including structural or organizational barriers that distort power and authority, the gap between professional values and bureaucratic expectations of behavioral norms, the potential for encroachment on professional boundaries, and the difficulties associated with establishing the effectiveness of clinical pharmaceutical services. Intradepartmental ambiguity may be rooted in structural flaws in departmental organization coupled with inappropriate management styles. If the pharmacy profession is to cope effectively with mounting ambiguity, a theory of clinical systems and practice management will have to be developed. This will require the knowledge, skills, and leadership of "bilingual" directors of pharmacy.

Strategic planning for clinical services: panel discussion.

A panel of hospital pharmacy managers representing three institutions discussed issues related to planning for patient-oriented pharmacy services. The panelists discussed organizational benefits of strategic planning, ways to gain momentum for change among pharmacy staff members and from others within the institution, the need for setting realistic goals, and problems in differentiating roles for pharmacy staff. They also discussed the funding of strategic-planning programs. The panelists advocated an integrated approach to providing drug distribution and clinical services. Management must provide whatever support is necessary for integrating patient-oriented services into the daily activities of all pharmacists. That support may be in the form of additional personnel, better use of supportive personnel, staff development programs, or automation. Pharmacists, too, must recognize their combined responsibilities for drug distribution and clinical services. Only by having all pharmacists clinically trained can a department provide clinical services when needed. The experiences of these panelists may be useful to other institutions planning patient-oriented pharmacy services.

Direct order entry by physicians in a computerized hospital information system.

Implementation of a policy encouraging direct order entry by physicians in a computerized hospital information system is described. A fully integrated database system was implemented in this tertiary-care university hospital. Terminals are available in the patient-care areas, order entry is uncomplicated, and typing is not necessary. When entering medication orders, the physician can select screens that display either general-order or specialty-order sets that are similar to preprinted-order sheets. A program was developed by the pharmacy and nursing departments to help the physicians learn to use the computer system and to demonstrate its benefits. Physicians were offered a training program that could be taken in one six-hour session or as six one-hour segments. Pharmacy technicians were trained to assist physicians with order entry in the patient-care areas during the implementation phase. Hospital policy requires that orders not personally entered by the physician must be written by hand in the patient chart and reviewed and entered in the computer system by a pharmacist before being dispensed. The delays inherent in this procedure give physicians an incentive to use the terminals. The policy encouraging direct order entry by physicians has been broadly accepted and has enabled the hospital to standardize drug therapy ordering and encourage adherence to the formulary.

Initial experiences with a pharmacy clinic in a hospital-based group medical practice.

Experiences in implementing a pharmacy clinic in a hospital-based primary-care group medical practice are described. A clinic was instituted through the joint support and active participation of the hospital administration and the departments of pharmacy and medicine. In the clinic, pharmacists monitored, assessed, and intervened in the drug therapy needs of patients who requested care or were referred by their primary-care physicians. Pharmacists provided services in 1751 patient visits during the first year of the clinic's operation. Clinic volume increased from two to 17 patients per session. Analysis of these patient visits showed that the pharmacists: (1) assessed physical signs in 60% of the patients, (2) ordered laboratory tests in 30%, (3) found a problem with the drug therapy in approximately one third of the patients, (4) detected new medical complaints in 4% of the patients, (5) initiated change in the drug regimen in 10% of the patient visits, and (6) referred almost 15% of the patients to new sources of care. In this clinic, pharmacists supplemented, not supplanted, the services of physicians for ambulatory patients.