Using Lean to Develop Frontline Clinical Staff Pharmacists as Residency Program Primary Preceptors

BACKGROUND AND LEAN JOURNEY

In 2007, a 4-hospital community health care system located in the East Metro area of St. Paul, Minnesota, started a system-based residency program that began with a single resident and later expanded to 2. In 2013, the program was modified and expanded to 3 site-based postgraduate year 1 (PGY1) residencies. This was done to help grow the residency programs and secure pass-through funding to financially support the resident positions within the organization. One of the sites is a 230-bed acute care facility with an average daily census of 190 patients. Twenty full-time equivalent clinical staff pharmacists are employed to manage over 11,000 admissions annually.

In late 2012, the health system began its process improvement journey to implement the Toyota Production System (ie, lean) across the enterprise. This initiative is called value-based improvement (VBI) and involves everyone in the organization, from frontline contributors to senior leadership. A key to the Toyota Production System is the implementation of the frontline management system (FMS), which engages the employees who do the work in the problem-solving and improvement process. Leaders coach and are “barrier busters” for improvement work done by frontline staff as part of FMS. This model puts the ownership of the change in the hands of those who are closest to the work.

Worth et al define lean as a set of concepts, principles, and tools used to create and deliver the most value from the customer's perspective while consuming the fewest resources by fully utilizing the skills and knowledge of those who do the work.1 In a lean system, frontline staff drive the majority of process improvement. A successful lean program improves efficiency and removes waste from the process, using less effort and time. Numerous examples of using lean for improvements with medication storage and distribution have been described in the literature, but we are not aware of any that describe improvements to precepting and residency programs.2–4 As a newer and recently modified program, we were looking to make improvements and decided to use a lean approach to preceptor development and overall residency program design.

PRECEPTOR TRANSITION FROM CLINICAL COORDINATOR TO FRONTLINE STAFF

Within the health system, the primary patient care responsibilities fall upon the decentralized clinical staff pharmacists through an integrated care model. Typical duties include order verification, participation in interdisciplinary rounds, antimicrobial management team rounds, renal dosing adjustments, intravenous to oral (IV to PO) conversions, kinetics, medication histories, and discharge medication review. Clinical pharmacy coordinators support the direct patient care responsibilities of the clinical staff pharmacists. They are tasked with duties such as order set review and revision, representation of the pharmacy department on clinical provider councils and nurse practice councils, policy and procedure review, medication safety event review and follow-up, guideline development and education, and completion of formal medication utilization evaluations. During the initial period as a system-based residency program, the clinical pharmacy coordinators served as the primary preceptors for the residency program's direct patient care learning experiences. This role was largely delegated to those individuals because they met the requirements of the Accreditation Standards when the residency program first started.5 The number, depth, and training of the clinical staff pharmacists has grown substantially over the past 9 years, which has allowed for additional individuals to be considered for the role of a primary preceptor.

Ensuring that every clinical staff pharmacist had time to achieve 4 of the 7 ASHP preceptor requirements was essential to the success of our preceptor model change. As a critical factor within the residency accreditation standards, meeting 4 of the preceptor requirements as set forth by the ASHP Standards for PGY1 Pharmacy Residencies was the major focus when shifting the responsibility to frontline clinical staff pharmacists. Over the course of a year, the Residency Program Director mentored each member of the Residency Advisory Committee (RAC) to develop an individualized plan for them to meet the requirements of the standards. Working as a group to ensure each primary preceptor satisfied the requirements of the standard helped us achieve the goal of all 9 primary preceptors meeting at least 4 of the required standards.

Each clinical staff pharmacist was tasked with updating his or her academic professional record every 6 months leading up to the change. After each update, the RAC reviewed opportunities for each primary preceptor to improve upon this critical factor. Applying the principle of standard work to ensure all primary preceptors are meeting 4 of 7 standards has led to the creation of a culture of continuous improvement to sustain success.

One of the major challenges to implementing this model was ensuring the clinical staff pharmacists had time in their day to precept. Given that they are hourly employees, it was not feasible for them to stay past their standard shift times to precept. To address this challenge, we decided to have a focused effort on preceptor development over the subsequent 2 years. Multiple modalities for preceptor development were employed to ensure that various learning styles were addressed.6 Some of the development strategies that were utilized were formal presentations on basic precepting skills and feedback, creation of a preceptor toolkit, round table discussions, “preceptor tip of the day” at VBI huddles, a 10-month long leadership book club, and leadership or precepting pearl presentations at RAC. Most of these strategies were led by the primary preceptors.

REFLECTIONS OF THE CHANGE

The clinical staff pharmacists have experienced the positive effects of a change to a site-based residency program. Having residents on-site everyday has increased department engagement and raised the amount of development occurring among the preceptors. Additionally, training residents has pushed all staff, especially primary preceptors, to obtain new skills and knowledge. Many of the staff are residency-trained, board-certified in their specialty area, attend and/or present at professional meetings, or pursue other career development opportunities.

The clinical pharmacy coordinators are involved with the residency program by providing research project support and oversight, holding topic discussions, developing new primary preceptors, and serving as content experts for the various clinical areas. Their partnership with the clinical staff pharmacists in precepting is one of the major reasons the program has become so successful in a relatively short period of time.

The concept of continuous quality improvement was the centerpiece for the movement away from the clinical pharmacy coordinators as primary preceptors. Shifting the primary preceptor responsibility to frontline clinical staff pharmacists allowed for those individuals who are providing daily direct patient care services to be the drivers of learning. Active practice and recognition of frontline clinical staff pharmacists by the interdisciplinary team of practitioners in which they precept is an easy sell to learners because they see it happen every day. Engagement in a lean system that allows for assessing and developing performance improvement initiatives related to education, training, and coaching made for a successful transition of the residency primary preceptor role to frontline clinical staff pharmacists.