Alison S. Roberts

Practice Change in Community Pharmacy: Quantification of Facilitators

Background: There has been an increasing international trend toward the delivery of cognitive pharmaceutical services (CPS) in community pharmacy. CPS have been developed and disseminated individually, without a framework underpinning their implementation and with limited knowledge of factors that might assist practice change. The implementation process is complex, involving a range of internal and external factors. Objective: To quantify facilitators of practice change in Australian community pharmacies. Methods: We employed a literature review and qualitative study to facilitate the design of a 43-item “facilitators of practice change” scale as part of a quantitative survey instrument, using a framework of organizational theory. The questionnaire was pilot-tested (n = 100), then mailed to a random sample of 2000 community pharmacies, with a copy each for the pharmacy owner, employed pharmacist, and pharmacy assistant. The construct validity and reliability of the scale were established using exploratory factor analysis and Cronbachs α, respectively. Results: A total of 735 (37%) pharmacies responded, with 1303 individual questionnaires. Factor analysis of the scale yielded 7 factors, explaining 48.8% of the total variance. The factors were: relationship with physicians (item loading range 0.59–0.85; Cronbachs α 0.90), remuneration (0.52–0.74; 0.82), pharmacy layout (0.52–0.79; 0.81), patient expectation (0.52–0.85; 0.82), manpower/staff (0.49–0.66; 0.80), communication and teamwork (0.37–0.65; 0.77), and external support/assistance (0.47–0.69; 0.74). Conclusions: All of the factors demonstrated good reliability and construct validity and explained approximately half of the variance. Implementing CPS requires support not only with the clinical aspects of service delivery, but also for the process of implementation itself, and remuneration models must reflect this. The identified facilitators should be used in a multilevel strategy to integrate professional services into the community pharmacy business, engaging pharmacists and their staff, policy makers, educators, and researchers. Further research is required to determine additional factors impacting the capacity of community pharmacies to implement change.

Implementing cognitive services in community pharmacy: a review of facilitators used in practice change

Objective To investigate facilitators of change in community pharmacy and their use in the implementation of cognitive pharmaceutical services (CPS).

Understanding practice change in community pharmacy: a qualitative research instrument based on organisational theory

Introduction: The past decade has seen a notable shift in the practice of pharmacy, with a strong focus on the provision of cognitive pharmaceutical services (CPS) by community pharmacists. The benefits of these services have been well documented, yet their uptake appears to be slow. Various strategies have been developed to overcome barriers to the implementation of CPS, with varying degrees of success, and little is known about the sustainability of the practice changes they produce. Furthermore, the strategies developed are often specific to individual programs or services, and their applicability to other CPS has not been explored. There seems to be a need for a flexible change management model for the implementation and dissemination of a range of CPS, but before it can be developed, a better understanding of the change process is required. Objectives: This paper describes the development of a qualitative research instrument that may be utilised to investigate practice change in community pharmacy. Specific objectives included gaining knowledge about the circumstances surrounding attempts to implement CPS, and understanding relationships that are important to the change process. Methods: Organisational theory provided the conceptual framework for development of the qualitative research instrument, within which two theories were used to give insight into the change process: Borums theory of organisational change, which categorises change strategies as rational, natural, political or open; and Social Network Theory, which helps identify and explain the relationships between key people involved in the change process. Results: A semi‐structured interview guide was produced, combining the factors affecting practice change found in the literature that warranted further investigation with the theoretical perspectives of organisational change and social networks. To address the research objectives, the instrument covered four broad themes: roles, experiences, strategies and networks.Conclusion: The qualitative research instrument developed in this study provides a starting point for future research to lead to a description and understanding of practice change in community pharmacy, and subsequent development of models for the sustainable implementation of CPS.

Providing Patient Care in Community Pharmacies in Australia

OBJECTIVE To describe Australias community pharmacy network in the context of the health system and outline the provision of services. DATA SYNTHESIS The 5000 community pharmacies form a key component of the healthcare system for Australians, for whom health expenditures represent 9% of the Gross Domestic Product. A typical community pharmacy dispenses 880 prescriptions per week. Pharmacists are key partners in the Governments National Medicines Policy and contribute to its objectives through the provision of cognitive pharmaceutical services (CPS). The Third Community Pharmacy Agreement included funding for CPS including medication review and the provision of written drug information. Funding is also provided for a quality assurance platform with which the majority of pharmacies are accredited. Fifteen million dollars (Australian) have been allocated to research in community pharmacy, which has focused on achieving quality use of medicines (QUM), as well as developing new CPS and facilitating change. Elements of the Agreements have taken into account QUM principles and are now significant drivers of practice change. Although accounting for 10% of remuneration for community pharmacy, the provision of CPS represents a significant shift in focus to view pharmacy as a service provider. Delivery of CPS through the community pharmacy network provides sustainability for primary health care due to improvement in quality presumably associated with a reduction in healthcare costs. CONCLUSIONS Australian pharmacy practice is moving strongly in the direction of CPS provision; however, change does not occur easily. The development of a change management strategy is underway to improve the uptake of professional and business opportunities in community pharmacy.

Flexibility in community pharmacy: a qualitative study of business models and cognitive services

Objective To identify the capacity of current pharmacy business models, and the dimensions of organisational flexibility within them, to integrate products and services as well as the perceptions of viability of these models. Methods Fifty-seven semi-structured interviews were conducted with community pharmacy owners or managers and support staff in 30 pharmacies across Australia. A framework of organisational flexibility was used to analyse their capacity to integrate services and perceptions of viability. Data were analysed using the method of constant comparison by two independent researchers. Results The study found that Australian community pharmacies have used the four types of flexibility to build capacity in distinct ways and react to changes in the local environment. This capacity building was manifested in four emerging business models which integrate services to varying degrees: classic community pharmacy, retail destination pharmacy, health care solution pharmacy and networked pharmacy. The perception of viability is less focused on dispensing medications and more focused on differentiating pharmacies through either a retail or services focus. Strategic flexibility appeared to offer pharmacies the ability to integrate and sustainably deliver services more successfully than other types, as exhibited by health care solution and networked pharmacies. Conclusion Active support and encouragement to transition from being dependent on dispensing to implementing services is needed. The study showed that pharmacies where services were implemented and showed success are those strategically differentiating their businesses to become focused health care providers. This holistic approach should inevitably influence the sustainability of services.

Implementation of cognitive pharmaceutical services (CPS) in professionally active pharmacies

Objective To investigate the implementation process of cognitive pharmaceutical services (CPS) in ‘professionally active’ pharmacies in Denmark; to describe the factors that influence the implementation process in the context of organisational theory.

A system for monitoring quality standards in the provision of non-prescription medicines from Australian community pharmacies

There is a growing trend, globally, for consumers to self-medicate with non-prescription medications for common ailments. Pharmacists and pharmacy assistants are thought to be in a unique position to support consumers’ purchases of these medicines through the application of knowledge and skills, in an environment in which safety and quality remains paramount. Standards of practice have been developed by the profession to address the provision of these medicines, using a consumer-focused and risk management approach.The application of these standards has been monitored since 2002, by the Quality Care Pharmacy Support Centre (QCPSC), created as a joint venture between the University and the Pharmacy Guild of Australia. The establishment of the QCPSC has allowed the development of a system to monitor and improve the application of standards for the provision of non-prescription medicines to consumers in community pharmacies in Australia. This system is unique in two aspects. The first is the use of pseudo-patient methodology, also called “mystery shoppers”, “pseudo-customers” and “simulated patients”, for the purpose of both assessment and quality improvement. The second unique aspect is the capturing of data based on assessments of behaviour in practice environments.To date, the centre has conducted 14,738 standards maintenance assessment (SMA) visits, involving over 4,200 pharmacies across all states and territories in Australia. The data generated by such a system create a feedback mechanism for policy decision-making in the area of Quality Use of Medicines (QUM) for non-prescription medicines, which is of critical importance to the health and safety of consumers.

Monitoring quality standards in the provision of non-prescription medicines from Australian Community Pharmacies: results of a national programme

Introduction: Standards of practice have been developed by the pharmacy profession to address the provision of non-prescription medicines, using a consumer-focused and risk management approach. The application of these standards in Australian community pharmacies has been monitored since 2002 by the Quality Care Pharmacy Support Centre (QCPSC). Methods: Between September 2002 and September 2005, 7785 standards maintenance assessment visits were conducted in 4282 pharmacies, using pseudo-patient methodology. 1909 were symptom-based requests (SBRs) and 5876 were direct product-based requests (DPRs), of which 2864 were for pharmacist-only medicines (POMs) and 3012 were for pharmacy medicines (PMs). 2756 pharmacies received two visits, and 747 received three visits. A pharmacy’s performance was scored out of 10 at each visit (scores 0–3: “unsatisfactory”; 4–6: “satisfactory”; and 7–10: “excellent”). Results: There was wide variation in performance at baseline, with 1453 (34%) of pharmacies scoring ⩽3, 1851 (43%) scoring 4–6, and 978 (23%) scoring 7–10. Significant improvement was seen over time (p<0.001), the mean score increasing by 5% from 4.4 (2.6) at visit 1 to 4.9 (2.6) at visit 2, and by 10% to 5.4 (2.6) at visit 3. Subanalyses to control for the effect of scenario type and medicine type showed that performance was higher for SBRs than DPRs, but the latter showed greater improvements over time. Conclusion: Repeated pseudo-patient visits lead to notable improvement in behaviour in the handling of non-prescription medicines in community pharmacies. A range of factors need to be considered when measuring these behaviours, such as scenario or medicine type, as they have considerable influence on performance. Future research should focus on issues of quality control, to better understand what makes some pharmacies perform satisfactorily and others unsatisfactorily, and what is required to shift performance from “satisfactory” to “excellent”.

Implementing cognitive services in community pharmacy: a review of models and frameworks for change

Objective To investigate models and frameworks for the implementation of cognitive pharmaceutical services (CPS) in community pharmacy.

Implementation of cognitive pharmaceutical services in Danish community pharmacies — perceptions of strategists and practitioners

Objective To understand how projects for the implementation of cognitive pharmaceutical services (CPS) are perceived as facilitators of change from the perspectives of practitioners and strategists. Setting Sixteen community pharmacies in Denmark and three organisations working on implementing CPS in pharmacy practice.