Change Identification and Ethics

Implementation Science

• the scientific study and application of strategies to promote the systematic uptake of research findings and other evidence-based practices into routine use, thereby improving the quality and effectiveness of health services

• focus on the what, how, when. and who of implementation rather than with discovering the why or creating an innovation

Change Management

• methods and manners in which a company describes and implements change within both its internal and external processes

• includes preparing and supporting employees, establishing the necessary steps for change, and monitoring pre and post change activities to ensure successful implementation

Before implementation, what must happen?

• identify a need for change

• think how we do this differently to improve safety, maximize efficiency, and be most cost effective

Functional Fixedness

• the inability to realize that something known to have a particular use may also be used to perform other functions

• a cognitive bias that makes you less creative

Process Change Triangle (PCT)

• Success:

• Leadership/Sponsorship:

• project management:

• change management

• framework that shows the four critical aspects of any successful change effort

• Prosci

PCT Success

define success for your change (include reason for change, objectives, and org benefits)

PCT leadership/sponsorship

direction and guidance for a project (include who is accountable for defining why change is happening, how it aligns with org direction, and why it is priority)

PCT project management

The discipline that addresses the technical side of a change by designing, developing, and delivering the solution that solves a problem or addresses an opportunity within the constraints of time, cost, and scope

PCT Change management

the discipline that addresses the people side of the change, enabling ppl to engage, adopt, and use the solution

ADKAR Methodology

• must create awareness FIRST of need for change

• awareness

• desire

• knowledge

• ability

• reinforcement

Deloitte future of health vision

• greater emphasis placed on preventative care over tx

• transition to more care being delivered in the home or community vs acute care

• profession is at crossroads from product-focused role to more of clinical role

• traditional education/practice models vs opportunities

Areas of opportunity for pharmacists to contribute to public/pop health

• primary care

• specialty care

• digital health

• population health analytics

Pharmacist role in primary care

• supplement/extent PCP services

• help pts better self manage conditions before acute/complex care required

• good for community pharmacists

• chronic condition management

• prevention and wellness

• minor acute illnesses

• behavioral and mental health

• aging in place

• addressing SDOH

Pharmacist roles in specialty care

• area of evolution for clinical pharmacist

• builds upon best practices of health systems that have imbedded pharmacists into care teams

• physicians make diagnosis, pharmacists take it from there

• pharmacist involvement in specialty therapies/complex tx protocols: procurement, storage, admin, monitoring, billing

Digital Health

• combine meds with digital companions

• pharmacist can assist with finding most appropriate digital health product, assist with setup, and educate on usage, self management, result interpretation, troubleshoot, and submission into EHR

• expanded DME opportunity with onsite use or rental for digital health products that are cost prohibitive

• remote pt monitoring

Population Health Analytics

• imbed pharmacists in payer orgs (managed care/insurance) and integrated delivery systems

• pharmacist have innate ability to evaluate clinical evidence and think in terms of numbers needed to treat or level of penetration that would bring improvement at population level

• analyze health outcome data, identify trends, design and test population health interventions that may involve care/case management and updating clinical pathways to incorporate latest evidence base

• design and test algorithms that could automate analysis

• involvement in development of decision-support tools beyond pharmacy

Structural barriers to shifting pharmacy paradigm

• payment models assign >value to product dispensed than to clinical services and improved pt outcomes

• segregation of medical and pharmacy benefits creates disincentives for payers and providers to consider pharmacy as component of care (supports separation of community and clinical pharm)

• retail and mail-order pharmacies owned by PBMs directly compete with non-PBM owned pharmacies

• product related revenue opportunities are more tempting than service related opportunities

Operational and Technical barriers to shifting pharmacy paradigm

• limited access to pt health record (data silos)

• productivity metrics place value on transactions

  • speed/quantity of rx/order filled → disincentives for pharmacists to perform clinical activites

  • documentation of clinical interventions

• real time claims adjudication + adaption of pharmacy systems to submit medical claims

• pharmacists may need to enroll in health plans’ medical provider networks (requires NPI), credentialing, contracting, and privileging

morals

personal principles regarding right and wrong

internal compass

ethics

systematic rules provided by an external source

professional guidance

ex. professional code

Professional ethics in pharmacy

• APhA code of ethics for pharmacists

• established to guide pharmacists in relationships with pts, health pros, and society

• key points: respect for pt autonomy/dignity, commitment to pts’ well being, honesty and integrity in professional relationships, professional competence and lifelong learning, and respect for colleagues and other healthcare professionals

Autonomy

honoring pts’ rights to make informed decisions

Beneficence

acting in the pt’s best interest

Non-maleficence

do no harm

justice

fair and equal treatment

fidelity

maintaining trust and confidentiality

Conscientious objections

• dispensing emergency contraception

• dispensing meds for assisted suicide

• providing hormonal therapy for gener affirmation

• prescribing or dispensing birth control pills

• participating in needle exchange or naloxone distribution

• refusing to fill prescriptions for certain off label uses

Controlled substances ethical dilemmas

• filling rx that may be misused or abused

• early refills or lost/stolen med claims

• forged/altered rx

• chronic pain vs opioid crisis

• prescribing behavior of certain prescribers

• dispensing to pts with known substance use disorders

• pressure from pts or family members

conflict of interest dilemmas

• financial incentives for recommending specific meds or products

• dispensing from pharmacy the pharmacist owns or has stake in

• relationships with pharma reps

• dual employment or consulting roles

• family/friends as pts

• influence on therapeutic interchange decisions

• ownership of related health business