A case study in mobilizing all pharmacy team members in the community setting

Background

The scope of practice of both pharmacists and pharmacy technicians is increasing. Across Canada, some pharmacists are able to adapt prescriptions, extend prescription repeats, perform medication reviews, independently prescribe drugs, order laboratory tests or administer injections.¹ Similarly, pharmacy technicians across Canada are increasingly becoming part of a regulated profession, allowing them to fulfill a greater role in both dispensing medications and patient care.²

With expanding patient care activities in community pharmacies, increasing demands are being placed on both community pharmacists and pharmacy technicians. To accommodate these demands, workflow modifications in terms of traditional roles and responsibilities in dispensing medications and providing patient care are increasingly necessary. Beyond their new dispensing role, technicians are also an untapped resource in facilitating pharmacists’ provision of patient-centred care.

According to the National Association of Pharmacy Regulatory Authorities (NAPRA), the vision for pharmacy technicians is that they “will work in collaborative relationships and will be committed to patient-centred, outcomes-focused care.”³ To realize this vision, NAPRA has developed a set of competencies for entry-to-practice of pharmacy technicians, which form the basis of national examinations and licensure of regulated technicians.³

In this case study, we present 2 successful examples of progressive technician facilitation of pharmacists’ patient care activities in the community setting. Using these examples as a starting point, we then outline one possible approach for the greater utilization of pharmacy technicians’ expanded scope when designing and implementing patient care programs in community pharmacies.

Methods

In this case study, we conducted opportunistic semi-structured and informal interviews with 2 community pharmacist and technician pairs who have developed successful pharmacist/technician working relationships to facilitate patient care activities. The researchers had come to know participants through their taking part in a number of pharmacy practice research studies and various professional associations. Given the authors’ backgrounds in pharmacy practice research, these activities presented a unique opportunity to demonstrate a model of pharmacist/technician collaboration for a wider pharmacy audience.

Interviews took place over the phone and via e-mail. Due in part to the different data collection approaches, interviews were not recorded, but all e-mails were saved and extensive notes of all phone interviews were taken. All analyses were also fed back to respondents to ensure clarity and allow for elaboration of thoughts. All data were analyzed using qualitative content analysis.

Results

The participating teams were from a chain pharmacy in urban Alberta and an independently owned pharmacy in rural British Columbia. The participating individuals and their practice sites are described in Table 1. In both pharmacies, the pharmacist involved in the collaborative team was also the pharmacy manager and therefore juggled both administrative and clinical duties.

Table 1.

Pharmacist/technician team participants

	Pharmacy A		Pharmacy B
Location	Alberta		British Columbia
Community population (approx.)	90,000		4000
Weekly prescription count (approx.)	4500		3300
Full-time equivalent pharmacists	4		4
Full-time equivalent technicians	3		5
Pharmacy type	Chain		Independent
	Pharmacist	Technician	Pharmacist	Technician
Sex	M	F	M	F
Years in practice	17	18	35	4
Additional qualifications	Certified Diabetes Educator (CDE), Certified Insulin Pump Trainer (CPT)	Regulated pharmacy technician	Hospital Residency	Regulated pharmacy technician
Years pharmacist and technician have worked together	10		4

Both teams have worked together for many years, and consequently describe relationships with a high degree of mutual trust. Each of the pharmacists reported that an expansion in clinical services offered by their pharmacy required a modification of the pharmacist and technician roles to ensure pharmacist time was reserved for activities requiring their clinical expertise. These technicians were selected for delegation of duties due to their experience, conscientiousness and willingness to expand their role.

While the technicians were initially delegated administrative duties such as appointment scheduling, this role was further expanded as mutual trust developed. The technicians now perform a number of facilitation tasks, including transcribing pharmacists’ care notes into reports for communication to other health professionals, drawing up of injections for flu clinics or travel medicine consultations, completing a best possible medication history, identifying patients who may benefit from a pharmacist consultation based on medication use and adherence, compression stocking fittings and device training, and collating patient information, including dispensing records and laboratory results prior to rounds at local care homes. Both technicians, who had recently become regulated, are also checking prescriptions prepared by other technicians to further free up the pharmacists’ time for direct patient care.

Both teams report greater professional satisfaction as a result of the redistribution of roles. Moreover, the teams also reported greater pharmacy efficiency, with reduced duplication of effort, allowing the pharmacists to focus their time on activities requiring their clinical expertise. From a business perspective, both pharmacists report that delegation of nonclinical tasks to technicians has allowed for greater capacity for billable services, introducing a new and significant revenue stream for the pharmacy. For example, within the first 2 weeks of offering flu vaccines in fall 2012, one of the pharmacies administered 1200 vaccines (billable at $20 each in Alberta).⁴ The pharmacist and technician credit this high volume to the efficiency with which the service could be offered as a result of delegation of duties. The technician marketed the service through in-store advertising and offering vaccination services when patients picked up prescriptions. The technician also phoned high-risk patients to book appointments, coordinated onsite clinics with local retirement homes, prepared supplies for injection administration, monitored inventory of the vaccine and performed documentation and billing. This enabled the pharmacist to focus his time strictly on performing assessments regarding the appropriateness of vaccination and the actual administration of the vaccine.

Discussion

Recognizing the limitations of such a small sample, the pharmacies discussed here exemplify one approach to how the expanding role of pharmacy technicians can be optimized to facilitate the provision of direct patient care activities in community pharmacies. Pharmacist and technician collaboration can result in greater job satisfaction, increased capacity to provide patient care services and an additional revenue stream for community pharmacies. Technicians can and should facilitate this by performing background activities related to the identification and organization of consultations, reserving pharmacists’ time for care activities requiring their clinical expertise.

These interviews conducted with pharmacist/technician pairs, practising under different provincial legislations, in different types of pharmacy and physical locations, demonstrate that successful collaboration can be achieved across various settings. Mutual trust, a desire to provide patient care services on both the part of the pharmacist and technician, and a willingness to delegate were identified as key components of a successful collaborative relationship. Importantly, the delegation of duties evolved over time, as trust was established and additional clinical services were introduced by the pharmacy, leading to the highly collaborative practices in place today. It is also important to note that all tasks performed by the technicians, with the exception of compression stocking fittings, are part of their standard training.³

Change management literature can provide guidance to pharmacists on how to implement new services and adapt professional responsibilities. For instance, pharmacies not currently delegating nondispensing tasks to technicians to facilitate patient care programs are encouraged to start by identifying an area of need and opportunities for service expansion.⁵ This may include monitoring and care for patients with diabetes or hypertension, or may even be as simple as offering compliance packaging, including medication reconciliation and reviews of safety and effectiveness prior to starting packaging for new patients. It is also important to establish a vision for the service.⁴ What would you like the outcome of this service to be? How would you expand this service once you have established yourself? How do you want your pharmacy to be known within your community? You must communicate this vision to staff and mobilize both technicians and pharmacists to extend their trusting patient relationships and begin to introduce the new services.⁴

Regular program evaluation and dialogue on the responsibilities shared between the pharmacist and technician will help ensure maintenance and renewal of the programs offered. Once the first service has been successfully implemented, expansion can be explored in terms of new clinical services or the participation of more pharmacists and technicians. Pharmacists considering developing a new clinical program are encouraged to consult the NAPRA competencies for pharmacy technicians for guidance on areas for technician involvement. Selected competencies and examples of technician application of that competency to facilitate patient care are provided in Appendix 1 (available at cph.sagepub.com/supplemental).

When considering the case of these 2 pharmacies, it important to note that both pharmacists and technicians invested considerable time and effort in transitioning their practices. Any practice change initiative will face barriers as it is being integrated into practice. While such barriers have not yet been formally studied, potential barriers such as pharmacist and/or technician concerns about liability, willingness to change, employer expectations of a pharmacist’s and technician’s role, and the availability of adequate remuneration for services to offset technicians’ time may be identified. As these or other barriers are brought to light, efforts will need to be made to appropriately remediate them.

Clinical pharmacy programs typically suffer from poor implementation and low numbers of patients accrued. Technicians can be systematic and recruit more patients because of their regular engagement with patients as part of the dispensing process. The use of technicians for facilitating clinical services makes economic sense for 2 reasons. First, more patients recruited for billable services means a greater income for the pharmacy. Second, mobilizing a lower-cost team member to identify patients and perform nonclinical tasks saves the pharmacist’s time for performing those billable services and may therefore increase the number of patients who can receive this care.

Conclusion

As the health care needs of patients grow more complicated, the provision of health care is becoming increasingly collaborative in an effort to meet those needs. This collaborative spirit should not only be extended to professionals outside the pharmacy but should also be occurring within pharmacies between pharmacists and technicians to enhance the provision of direct patient care. Nonclinical activities can be easily delegated to regulated technicians in the community pharmacy setting, resulting in improved professional satisfaction, enhanced patient care opportunities and economic benefits for the pharmacy as a result of billing for professional services. ■