PRACTICE FOUR
Leadership Taking on Roles in Guiding the Program Development
Multiple types of leadership in the PBDMP guided the administration’s program development. Institutionally, El Rio administrators and top clinic leadership were
supportive of the project goals throughout the lifecycle of the program—from initiation to present day. Departmentally, clinicians from the family and internal medicine
departments were supportive of the program and took on leadership roles for care coordination for patients.
Institutional Leadership
The concept of leadership was discussed in multiple forms. Influential individual leaders were specified and teams of leaders were also discussed. The leadership choices that were made institutionally in support of the creation of an outpatient clinical
pharmacy program, were also described in many of the interviews. The Program
Director of El Rio mentioned the founder of the PBDMP, “And, so, I think he saw a need from the pharmacy director’s perspective, I think he really, like just understood the value pharmacists could bring in this type of model. Moving away from the dispensing role and actually making clinical interventions.” These types of decisions made at a high level to direct the focus of the future PBDMP were a key element for program formation.
A key factor identified in the El Rio key informant interviews was the El Rio leadership creating an institutional culture of openness and experimentation. The Administrator from El Rio discussed the culture of El Rio, “I mean there’s obviously entry barriers whether you need may resources or money or whatever you might need.
But, from an organizational culture, perspective, nobody says, no, Julia, we don’t want to talk about that or we don’t want to do that. So, any idea that’s presented, I find people are willing to talk about it and examine it and […] entertain it.” This open attitude from the top leaders at El Rio instilled a culture of innovation throughout the clinic.
Moreover, innovation was reflected during the Pharmacist Group brainstorming session about pharmacist education and best practices. The El Rio Program Director created an internal website for pharmacists, RxPrescribingPearls, to share their best practices and innovations about drug therapy and patient care delivery. The website innovation served as a tool for “Pearls” of information to be shared between PBDMP pharmacists. As discussed in Practice Three, the freedom for the pharmacists at the UNC program to innovate and create the current UNC Enhanced Care Program was another example of the culture of support for new ideas.
The “Administrative support” was mentioned as a success of the program in multiple data sources and specifically identified in the Pharmacist Group RCA diagram.
This support pointed to both financial and ideological support throughout program creation and implementation. The Program Director of UNC noted that after receiving the buy-in from clinic leadership, they understood what pharmacists could offer to clinical services, “And so they’re very very [sic] receptive to what we can do and I think they’ve also shown other clinics the impacts that pharmacists can have and what they can do for them.” The support from management was both a resource and a key element of leadership for the clinic as well as the outpatient clinical pharmacy program itself.
Departmental Leadership
From a program standpoint, the strong leadership in the PBDMP was described through hiring practices that sought specific individual personality traits for program employees. The administrators discussed the personality traits that were most desirable with the PBDMP staff for future employees and sought individuals to join the team that were most in line with these characteristics. However, the identification and weight given to each of these specific skills in potential employees were less tangible from the data. For example, the Pharmacist Group RCA diagram described the “motivated team”
that was hired and mentioned that the leadership “hired well: [employees have] thick skins.” Clinicians, administrators and pharmacists themselves described the PBDMP staff as “friendly/accessible,” “accountable,” and “highly qualified.” These
characteristics of individuals hired for the PBDMP team pointed directly to the clear vision and leadership of program directors in addressing personality matches within
program staff themselves. The brainstorming group also directly credited the
“management’s knowledge of staff” praising the program leaders’ involvement and familiarity with the PBDMP employees.
The Administrator at El Rio pointed to the specific involvement of the PBDMP Program Director’s leadership as a key driving force behind the program’s creation and implementation, “I seriously have to go back to [PBDMP Director]’s leadership…if [PBDMP Director] wouldn’t have shown up here, I don’t think that would have happened. Because, you know, [PBDMP Director] was focused on that population.
Very interested in connecting other resources around it, so I really think that would be the key driver.” The PBDMP Program Director had experience working at the Veterans Administration and in the Kaiser Hospital system in anticoagulation and blood pressure clinics addressing chronic disease state management.
Through these past work experiences, the Director was able to shape the current and future state of the PBDMP, “I was able to take a lot of the things I really loved about other practices that were successful and not in diabetes necessarily…there were elements of the care that the pharmacists were providing there that I really liked, that brought those in, and then there were things I didn’t like. And, I didn’t include those. And, then I made sure that we had things like, well, things that I saw that were deficient in other sites.
Like, having a nurse, like a medical assistant assigned to the pharmacist. Which in other practices, that’s not usual. We make that the standard here.” This vision and leadership combined with the experience of past working experiences shaped the PBDMP.
Program Leadership
There was not one definite way to begin or develop a successful outpatient clinical pharmacy program. However, clear vision and leadership were present in all of the clinics studied. Program leaders creatively shared patient outcomes with clinic leadership reinforcing the importance of the program. For example, systematically documenting positive impacts on a patient population and reporting those successes through a third-party reviewer in an objective format was imperative for administrative and clinical buy-in. The Director of the PBDMP explains that, “We did a lot of objective third-party evaluations…so that they could give us objective feedback, so that they could say, hey, yeah-this has, you know—it works! So that was it. And then we did a lot of things, publications, PR, we won awards that showed us to be exceptional like as compared to other practices in the country.” Other programs, like the MHC just started the program and brought in the administrators after full program implementation, “So, I kind of know what I want to do as a Pharmacy Director. And, I just pursue it. I don’t really wait for anyone’s approval to do what I want to do. I know it, it makes sense and it’s logical and then I present it to like my CEO—like, a year ago. I think this is the way I think we should go—I think this is the direction things are moving.” Strong vision and leadership were key drivers for program creation.
The data showed that the individual “[PBDMP Director]” and the “Recruits from [PBDMP Director]” were major successes of the PBDMP. The Administrative Group’s RCA diagram further identified the “PharmDs themselves” serving as leaders for the program. Another outcome identified by the Clinical Group’s RCA diagram was positive
leadership and participation in the program “PCPs learn from PharmDs” which in turn
“improves PCP [patient] management.” The brainstorming group identified that the product of good leadership and communication between program employees led to
“lower [hospital] admissions due to complications.” These positive externalities of the PBDMP were attributable to the strong vision and leadership shown by the PBDMP Director.
One of the barriers to successful implementation of the PBDMP was the
inundation of work that fell to the pharmacists. The Administrative Group RCA diagram identified that the program leadership needed to “streamline process by clinical
pharmacists to not do all the work.” In addition, the group identified that “using the team well” and “pharmacists not working at the top of licensure” were major concerns for program leadership. The administrators stressed that the program leadership needed to find ways to use all of the skills of each employee. While the group reflected on how they had utilized the skills of their employees, they pointed out that improvement was still needed. The Program Director at UNC noted that, “In the beginning, our manager in chief wasn’t as interested in pharmacy services, and so, wasn’t as big of an advocate within leadership and then that changed and luckily for us it became a physician that very much wanted to promote what pharmacists could do and utilize them to the top of their degree.” Finding the management support necessary to empower pharmacists to work at the top of their level was important for program success. While empowering employees to work to the top of their degree is still a barrier at many of the clinics, identifying the need for the delegation of work and beginning to seek solutions for these issues was a
component of active leadership from program and clinic leaders.
Conclusion
There were multiple types of leadership that actively guided the development of the PBDMP as well as in the outpatient clinical pharmacy programs. Leadership that actively guided the development of the PBDMP was identified at all levels of the clinics from the institutional, departmental, and programmatic level. Leaders worked to include all employees and key stakeholders during program creation and implementation. The culture of support and innovation at the PBDMP pointed to the clinic leadership’s and program staff’s willingness to change. The types of leadership models these activities described will also be discussed further in Chapter 5.