Practice Management Training in the PGY1 Residency Year: Best Practices From Two Nationwide Surveys

Abstract

Purpose:

The development of future pharmacy leaders is vital to the advancement of our profession. Postgraduate year 1 (PGY1) residency training requires residents to exercise leadership and practice management skills. Two national surveys were conducted to describe the current state of practice management experiences and elucidate best practice recommendations.

Methods:

The surveys, online multiple choice and free response, queried American Society of Health-System Pharmacists (ASHP)–accredited residency program practice management preceptors (survey 1) and PGY1 residents (survey 2) and were distributed via the ASHP residency program directors’ listserv. Responses were reviewed and analyzed by members of the University HealthSystem Consortium Pharmacy Council Strategic Initiatives and Programming Committee.

Results:

Survey 1, completed by 240 institutions, identified that a combination of concentrated and longitudinal practice management experiences were used most frequently (47%), followed by concentrated alone (33%). Universally noted activities included meeting attendance (98%), projects (94%), and committee involvement (92%). Sixty-seven percent of the programs changed the experience in the previous 3 years, with 43% planning changes in the coming year. Survey 2 was completed by 58 PGY1 residents from 42 programs. Most (80%) residents stated they had enough time with their preceptors, and 55% rated their enjoyment of the rotation as 4 or 5 on a 1 to 5 scale (5 = most enjoyed)

Conclusion:

Our findings suggest that there is not a best practice for the structure or content of the PGY1 practice management experience. These results highlight key recommendations, including the need for practice management-specific preceptor development, incorporation of longitudinal experiences, and more practice management and leadership activities.

Practice Management Training: A Professional Imperative

The purpose of postgraduate year 1 pharmacy (PGY1) residency training, as stated by the American Society of Health-Systems Pharmacists (ASHP), is an “opportunity to accelerate growth beyond entry-level professional competence in patient-centered care and in pharmacy operational services, and to further the development of leadership skills that can be applied in any position and in any practice setting.”¹ This purpose has evolved over the past several decades to include an increased focus on leadership development with the growing needs and expansion of the profession. This evolution is deemed necessary, as the US Bureau of Labor Statistics estimates that jobs for pharmacists will increase 25% by 2020.² Additionally, the American College of Clinical Pharmacist (ACCP) and ASHP envision all hospital and health-system pharmacists to be residency trained by that same year.^3,4 It is well documented that strong leadership is essential to attract talented staff, create an effective working environment, and advance the profession.⁵ However, there is growing concern that there will be a lack of emerging pharmacy leaders as current pharmacy leaders transition out of their positions. A survey by White⁶ published in 2005 found that 80% of pharmacy directors were planning to leave their position in the next 10 years. Another significant finding from the White survey was that 77% of directors did not think there was a qualifi ed replacement if they left. These results were a catalyst for ASHP to revise their standard in 2008 to include leadership in the key outcomes, goals, and objectives of pharmacy residency training.⁷

In a recent statement, ASHP re-affirmed its commitment to the development of pharmacy leaders across the spectrum of pharmaceutical care: “Leadership is not an option – it is a professional obligation.”⁸ Specifically, outcome 3 of ASHP’s PGY1 accreditation standards requires residents to “exercise leadership and practice management skills” with corresponding goals and objectives to achieve this outcome.¹

According to the ASHP PGY1 residency purpose statement, programs should provide a balance between clinical and leadership opportunities. Competing time and resources can cause disparity amongst programs around the country as they try to develop both clinically strong practitioners and future pharmacy leaders. In White’s study, ⁶ many residents, and even some current practitioners, cited finding the balance between purely clinical activities and leadership roles during a 1-year time frame as a challenge. However, some centers have described their success in striking this balance. For example, Fuller et al⁹ described several strategies used at one institution to develop leadership among pharmacy residents. This included leadership development meetings, article discussions, an annual resident retreat, and various leadership-based self-assessments. Furthermore, in Pollard et al,¹⁰ previous residents primarily reported that onthe-job training, life experience, and mentorship were the major contributors to their leadership experience.

Many residency programs have attempted to make the leadership experience more structured by incorporating practice management rotations. These rotations aim to expose residents to the administrative processes of managing a pharmacy and developing leadership skills. As no definitive standard of practice has yet to be established, multiple approaches are used. Rotation experiences vary, and they include longitudinal-style practice management, 4- to 8-week concentrated rotations, or a combination of the 2 approaches. There are a variety of activities and responsibilities for both preceptor and resident.

This report describes a set of national surveys that were conducted to describe the current strategies that ASHP-accredited residency programs are using to meet the residency standard to develop pharmacy leaders. It also describes the aspects of leadership and practice management training that residents and pharmacy directors find most useful.

Current Practice: Preceptor and Resident Perspectives

Methods

Two online multiple-choice and limited free-response surveys were distributed to ASHP-accredited PGY1 residency programs via the ASHP residency program directors’ listserv. Survey 1, distributed via an online survey tool in 2010, was a 20-question multiple-choice/limited free-response survey intended to be completed by the director of pharmacy or the alternative departmental leader involved in precepting practice management experiences for PGY1 residents. Survey 2, distributed via an online survey tool in 2011, was a 10-question multiple-choice/limited free-response survey that was to be completed by PGY1 pharmacy residents. The participants were given 3 months in which to complete the surveys prior to their closing. One reminder e-mail was sent during the open survey period.

Results

Survey 1: Preceptors’ practice management perspectives

Survey 1 was completed by 240 administrative preceptors and/or pharmacy directors representing 240 different residency programs (approximate response rate of 28% based on 820 ASHP-affiliated PGY1 residency programs nationwide). Of the 240 respondents, 88 (36.7%) were from a University HealthSystem Consortium (UHC)–affiliated institution. Surveyed programs had an established residency program for 1 to 5 years (18%), 6 to 10 years (29%), or 11 to 15 years (13%), with the plurality of residency programs having been established for more than 15 years (40%). Only 12.5% of programs surveyed reported having a PGY2 pharmacy practice management residency.

The majority of respondents were pharmacy practice management preceptors (90.8%); 36.7% also served as pharmacy director. The number of preceptors involved in training residents ranged from 1 to 5 (67.1%), with some institutions reporting having as many as 8 to 10 (8.4%). When queried about administrative roles held by practice management preceptors, most identified multiple roles. These roles included quality (20%), budgetary (18%), operations (17%), and human relations (13%). Other notable roles included formulary management, clinical, leadership, and regulatory. A small number of respondents reported being involved in all of these roles (2.5%).

The structure of the pharmacy practice management experiences provided to the residents was concentrated (33%), longitudinal (20%), or a combination of both (47%). Of those programs utilizing a concentrated method alone or in combination with a longitudinal experience, most (70%) utilized a 4-week rotation, followed by 5-week (13%) and 6-week (7%) durations.

With regard to the frequency of preceptor–resident interactions, the programs utilizing a concentrated experience typically met with their residents 2 to 6 times per week (60% of programs) in a scheduled structured setting (61%) as compared with an ad hoc (29%) or episodic manner (6%). Some programs (18%) reported meeting with residents 7 to 10 times a week during concentrated experiences. Longitudinal programs most often met one time per week (47%); however, 45 respondents (48%) selected “other” for the number of times they met with residents. These interactions were predominantly scheduled interactions (58%) as compared with ad hoc (25%) or episodic (12%). Results from the programs that reported a combination of concentrated and longitudinal experiences are difficult to interpret given the nature of this structure; however, they reported similar trends in the structure of interactions, with 41% and 28% as scheduled and ad hoc interactions, respectively.

Preceptors were queried about the activities that the practice management experience covered, such as committee participation, administrative on-call, and Pharmacy & Therapeutics (P&T) involvement. Respondents stated that, on average, 5.6 activities were covered during practice management rotations. Activities such as meetings (98%), administrative projects (94%), committee involvement (92%), and leadership development (89%) were virtually universal. Other common activities included presentations (75%), journal clubs (42%), seminars (30%), and manager on-call (14%). In programs that included human resources training (54%), residents were most frequently involved with staff interviews, staff evaluations, and team-building activities.

Resident career development was addressed through practice management experiences in a variety of ways: career mentorship (64%), interviewing tips (61%), and curriculum vitae (CV) preparation (47%). Salary negotiations (16%), professional organization involvement (3%), long-term professional development (<1%), and interview role playing (<1%) were rarely covered.

Optimization and development of the practice management rotation and management preceptors were also addressed in survey 1. Whereas two-thirds of programs reported making changes to the implementation of their experience in the past 3 years and almost half (43%) plan to make changes in the coming year, the vast majority (87%) reported that their current strategy for provision of the experience is working. Planned changes included diversification of management experiences, increased topic discussions and readings, and either incorporation of a longitudinal aspect to concentrated experiences or a shift from 4-week concentrated experiences to several short (1 week or administrative seminar-type) experiences throughout the year. The rationale that was given for changes in formatting was to better experience the breadth of administrative activities throughout the year. The tools and techniques for preceptor development in practice management used by surveyed programs included ASHP preceptor development tools (34%), institution-specific tools (24%), and attendance at the Foundation Pharmacy Leadership Academy (15%). Notably, 25% of institutions did not utilize any preceptor development tools, and the ACCP Academy Leadership and Management Certificate and The Ohio State University Latiolais Leadership Programs (LLP) were significantly underutilized by surveyed programs, with 2% and 0% use, respectively.

Survey 2: Residents’ practice management perspectives

Survey 2 focused on residents’ attitudes and opinions regarding their practice management experiences. It was completed by 58 PGY1 residents representing 42 different residency programs. Similar to survey 1, the structure of the practice management experience was concentrated (45%), longitudinal (17%), or a combination (38%) of both. The majority of respondents (80%) felt that they had enough time with their preceptors. A PGY2 practice management residency was available at 35% of programs; all of these programs involved the PGY2 resident in the PGY1 practice management experience. Most PGY1 residents (70%) found the PGY2 resident involvement helpful.

With regard to resident overall enjoyment of the PGY1 practice management experience, residents rated their administrative experience on a scale of 1 to 5 (1 = least enjoyed, 5 = most enjoyed), with 45% reporting a score of 4. Thirty-two percent rated their experience a 3, and 10% rated their experience a 5. Only 1 resident (2%) rated the experience as 1. Content that residents found most helpful included leadership/planning, committee involvement, and project management. The most commonly cited least helpful activities were related to purchasing, The Joint Commission, and budgetary issues.

Career development as a part of the PGY1 practice management experience was also evaluated. Just under half (47%) of residents reported that no career development was included in their practice management experience. Figure 1 depicts the different career development topics that residents found most useful, wish were covered, and were an overall utility (covered or wish were covered).

Figure 1.

Residents’ perspectives on career development topics in residency programs. CV = curriculum vitae.

Discussion and Best Practice Recommendations

Practice management and leadership training are critical aspects of the PGY1 residency year. The imperative to produce not only clinically effective practitioners but also future pharmacy leaders was reinforced by ASHP in 2008. At this time, ASHP revised its PGY1 residency standards to include outcome 3, which is dedicated to developing leadership and practice management skills. Anecdotally, time for practice management training is in continual conflict with clinical experiences during the busy 12-month PGY1 experience. This has lead to varied approaches in structuring the practice management experience. Additionally, given the wide variety of leadership and practice management topics and activities, from operational and clinical to C-suite or human resources, the content of practice management can vary widely among even similarly structured pharmacy departments across the country. The survey results presented underline the predominant opinion that no standard of practice exists regarding practice management and leadership training during the PGY1 year. However, several recommendations for best practice can be made to enhance practice management and leadership experiences.

Recommendation 1: All PGY1 pharmacy residency programs should include practice management–specific preceptor development in their overall preceptor development plan.

Having practice management preceptors actively engaged in preceptor development as well as development activities geared to leadership and practice management will help to further refine and expand experiences offered. Although many respondents described preceptor development activities, one-fourth utilized no preceptor development or practice management/leadership–specific tools. Programs such as the ACCP Academy Leadership and Management Certificate and The Ohio State University LLP were significantly underutilized in our sample. The ACCP Leadership Certificate program uses a combination of live classwork, readings, and mentorship aimed at developing leadership and management abilities.¹¹ The LLP provides resources from The Ohio State University pharmacy alumni group for pharmacists interested in health-system administration.¹² Incorporating practice management–specific preceptor development will engage preceptors who traditionally are not involved in clinically directed preceptor development. Another advantage of this type of preceptor development is that it may allow for more management-type experiences to be incorporated into traditional, clinical experiences, both concentrated and longitudinal. This allows the residents to observe the incorporation of valuable leadership skills into traditional clinical pharmacy activities.

Recommendation 2: PGY1 programs should consider incorporation of longitudinal practice management experiences either in combination with or in place of concentrated experiences.

The majority of programs surveyed currently have some longitudinal portion of their practice management experience; however, the most commonly cited change that had recently occurred or was planned for the structure of the experience was addition of a longitudinal portion. Reasons cited for this change included broader experiences, for example, budget planning during the fiscal year change, and increased ability to build upon the experience throughout the year as the resident gains a better understanding of management issues.

Recommendation 3: Incorporation of more practice management and leadership topics and activities throughout the practice management experience, with particular attention to career mentorship and leadership development.

One area for improvement identified by preceptors and residents was the content of the practice management experience. Content areas already covered by most programs include meetings, administrative projects, and committee involvement. In addition to these, residents and preceptors identified career mentorship (including salary negotiations, interviewing tips, and CV preparation), human resources such as staff hiring and discipline, and leadership building as topics warranting additional time during the practice management experience. Adding these more global topics to the day-to-day functionality of meeting and committee involvement may increase preceptor satisfaction and resident interest in administrative activities.

This study was unique, because it obtained information from both preceptors and current residents and allowed for additional comments. It was the first large-scale analysis of this topic among preceptors. Unfortunately, the resident perspective in this analysis was limited by the low response rate. Additional limitations include selection bias inherent in optional questionnaire-style assessments and variability in question response rate. A response to all questions was not required to successfully submit the survey, therefore some questions, particularly in the preceptor survey, had nonresponse rates of 10% to 25%. These results provide evidence of the differences between methods of providing practice management training during the PGY1 residency year. By incorporating longitudinal practice management experiences, including a wider variety of practice management and leadership topics, and ensuring continual growth of the practice management experience through preceptor development, PGY1 residency programs can utilize the practice management experience to enhance the training of the next generation of pharmacist and thereby help to fill the leadership void expected to occur in the near future.