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Pharmacies can create, build, or redesign a pharmacy microsystem process
Goals are to enhance PharmD leadership, safety
Hospital pharmacies can improve their own systems and promote pharmacists for hospital system leadership positions by using a microsystem design process to improve their care delivery.
Pharmacy directors might think about microsystems in terms of new technology, especially when they're installing a new barcoding system or computerized physician order entry (CPOE) system.
But it's about a great deal more than the technology, experts say.
"Technology is part of it, but people look to the technology to be a quick fix, and microsystem design is larger than that," says Marjorie Godfrey, MS, RN, co-director of the Dartmouth Institute Microsystem Academy at Dartmouth College in Lebanon, NH. Godfrey also is the director of the Clinical Microsystem Resource Group and is an instructor of the Dartmouth Institute for Health Policy and Clinical Practice.
The microsystem design involves understanding who the pharmacy's customers and partners are and having conversations with health system leaders and staff about why the department exists, she says.
"It's easy to assume that automation and information system technology will increase the safety net, improve our productivity, and enhance the outcomes and effectiveness of the care we deliver," says Sharon Enright, MBA, president of EnvisionChange of Richmond, VA.
"But the reality is we live in complex human systems, and there are so many factors that influence those outcomes well beyond the technology," she explains. "Those are the soft spots in our system."
The microsystem design process assists health systems in addressing those soft spots.
Like medical doctors, pharmacists are involved in the policy level of health systems. The pharmacy and therapy (P&T) committee is an important, policy-driven process that impacts medication prescribing and care, Enright notes.
Pharmacists who learn about microsystem design could use this process when developing process improvement that involves P&T committee reviews and work. This is an area that places pharmacist leaders at the front and center of hospital leadership.
"That makes microsystem design a much more powerful resource for pharmacy in developing a leadership role," Enright says.
The American Society of Health-System Pharmacists (ASHP) has highlighted microsystem design in its recent series of summer meetings. The organization's focus is on developing leadership skills for pharmacists to take a more aggressive role in medication safety, she adds.
Last year, the National Quality Forum updated its safe practices recommendations. These 34 recommendations emphasize the importance of pharmacy leadership at the highest levels of an organization, she explains.
For example, the safe practice 18 recommends that pharmacy leaders have an active role on the administrative pharmacist leadership team that reflects their authority and accountability for medication management systems performance across the organization.
Microsystems design provides a toolbox or pathway for pharmacists to use when attempting to achieve the goals of improving medication safety and enhancing pharmacist leadership activity, she adds.
Previous efforts at achieving these goals have been random, episodic, and isolated, Enright says.
"So this is an attempt to build a framework for thinking and standard methodology for pharmacists to build into their practice model," she says.
"The clinical microsystems approach is a comprehensive framework of thinking so you can develop a clear understanding of what the care process is," she explains. "Everyone shares the same view, and they can see where the gaps are and work together to fix those gaps."
The microsystem design process has been used by hospitals and other health care organizations, but its use in the hospital pharmacy is new.
"Our focus has been interdisciplinary in all of health care," Godfrey says. "The focus with pharmacy is new, although many pharmacists have been part of clinical microsystems."
There are about a dozen hospitals testing microsystem initiatives, and the goal would be to have a pharmacist cohort develop within the microsystem initiatives, Enright says.
Available microsystem resources include Greenbooks on inpatient care, emergency department, long term care, outpatient primary care, outpatient specialty care, and neonatal intensive care unit care. These are available as a free download in MS Word at the Dartmouth Institute Microsystem Academy website: www.clinicalmicrosystem.org.
The website is free and liberal, designed with the intention of redesigning and improving health care, Godfrey says.
Eventually, there will be resource information about microsystems that is specifically geared toward pharmacists, Enright says.
"Short of having comprehensive funding to do this whole project, we're working on ways to involve a small number of organizations in the initial coaching and to train people to teach microsystems in their teams," Enright says. "We'd like to develop some studies that would allow us to finalize the Greenbook and make this widely available."
A pharmacy microsystem team would include a pharmacist, pharmacy technician, and any other individuals in the hospital pharmacy.
"Most of our work to date is around clinical microsystems," Godfrey says. "We do have a draft book for pharmacies that leaders could use."
Ideally, hospital pharmacists would be able to learn microsystem design and implement it within the context of their health care system also adopting this process. But they can use a microsystem design on their own, if that is their only option, Enright says.
"You can always create demonstration projects that show results that are unique and different and get results that you can show the larger organization," she says. "I believe that using microsystems in a laser-focused area can allow you to achieve very unusual and attentionable results that might even allow you to bring it to the larger organization more quickly."
One initial project could involve a medication safety issue, Enright suggests.
For instance, a hospital pharmacy could focus on one of the National Quality Forum safe practices, such as the safe practice 17 of medication reconciliation. The microsystem process could help the organization develop and reconcile patients' medication lists throughout the health care continuum.
The microsystem design uses five "P's" as an outline of steps to take. These are as follows:
"This process fosters a different kind of dialogue that is deeper, richer, more detailed, and which allows people to think at a much less superficial level," Enright says.
The process essentially begins with assessing data to find an area that needs improvement. It's followed by developing a theme, which could be to improve efficiency. Then there's a global aim, followed by a specific aim, which would be one goal with a stated desired outcome. The next step involves brainstorming with staff, followed by taking measurements, and moving to the PDSA (plan, do, study, act) process for quality improvement initiatives.
Pharmacists who are interested in learning how to implement microsystem design should attend educational meetings on the process and then serve as a coach to others in their departments, Godfrey suggests.
Dartmouth holds spring and fall coaching series, but the commitment extends further and requires considerable time and effort, she adds.
It's a continuous journey, and microsystem leaders are never done because one process of improvement leads to another one, Godfrey says.
"You might have five different improvement initiatives running at one time," she explains. "Then you have to learn the methodology, be reflective, create a data wall where data is reported regularly, report errors, cycle times, and change the whole work environment."