Purpose The rationale for and logistics of the expansion of a postgraduate year 1 (PGY1) residency program in a community hospital are described.
Summary Baptist Health Lexington, a nonprofit community hospital in Lexington, Kentucky, sought to expand the PGY1 program by having residents perform second-shift decentralized pharmacist functions. Program expansion was predicated on aligning resident staffing functions with current hospitalwide initiatives involving medication reconciliation and patient education. The focus was to integrate residents into the workflow while allowing them more time to practice as pharmacists and contribute to departmental objectives. The staffing function would increase residents’ overall knowledge of departmental operations and foster their sense of independence and ownership. The decentralized functions would include initiation of clinical pharmacokinetic consultations, admission medication reconciliation, discharge teaching for patients with heart failure, and order-entry support from decentralized locations. The program grew from three to five residents and established a staffing rotation for second-shift decentralized coverage. The increased time spent staffing did not detract from the time allotted to previously established learning experiences and enhanced overall continuity of the staffing experience. The change also emphasized to the residents the importance of integration of distributive and clinical functions within the department. Pharmacist participation in admission and discharge medication reconciliation activities has also increased patient satisfaction, evidenced by follow-up surveys conducted by the hospital.
Conclusion A PGY1 residency program was expanded through the provision of second-shift decentralized clinical services, which helped provide residents with increased patient exposure and enhanced staffing experience.
National pharmacy organizations such as the American College of Clinical Pharmacy and the American Society of Health-System Pharmacists (ASHP) have pointed to the importance of residency training for practitioners who hope to participate in direct patient care.1,2 Furthermore, the Pharmacy Practice Model Initiative (PPMI) set forth by ASHP in 2010 calls for pharmacists to better meet the needs of patients by contributing to quality patient care and safety as members of patient care teams.3 This overarching goal is consistent with the focus of postgraduate year 1 (PGY1) residency programs throughout the United States.
Recently published data indicate that the increase in pharmacy graduates in the past decade has exceeded market demand, leading to a nationwide surplus of pharmacists.4 Many pharmacy school graduates pursue residency or fellowship training in an effort to gain knowledge and experience as well as specialized training, but graduates also understand that residency training is a prerequisite for many jobs.5 Competition for available residency positions is on the rise, and healthcare systems are increasingly requiring PGY1 residency training for entry-level positions.
As the number of pharmacy graduates continues to increase, so too has the number of applications for PGY1 positions, evidenced by a record number of applicants in 2013.6 The national challenge for community hospitals, in an effort to meet ASHP goals for residency training, is to increase available PGY1 residency positions to meet current demand.7,8 Consistent with this challenge, we describe the expansion of the PGY1 residency program at Baptist Health Lexington (BHL) by having residents perform second-shift decentralized pharmacist functions.
BHL is a nonprofit community hospital located in Lexington, Kentucky. BHL operates 383 licensed beds, including 42 intensive care unit (ICU) beds. Primary service lines include cardiology, oncology, and women’s health. Approximately 19% of emergency department visits result in inpatient admission, as a large part of the patient census comes from referrals from outlying communities in rural Central and Eastern Kentucky.
The pharmacy department at BHL dispenses an average of 5000 medication doses daily and is staffed with approximately 28 pharmacist full-time equivalents (FTEs), 8 of whom are residency preceptors, as well as 19 pharmacy technician FTEs. Full implementation of computerized prescriber order entry occurred in early 2014.
The pharmacy department relies heavily on automation. BHL installed the first pharmacy robot in Kentucky in 1998 and has used bedside barcoding since 2005. A clinical decision-support system, Sentri7 (Pharmacy OneSource, Bellevue, WA), was recently implemented to identify and document clinical interventions and adverse drug reactions. Automated storage and dispensing systems are used within the department, including two MedCarousel units (Aesynt, San Francisco, CA), and numerous automated dispensing cabinets are in use throughout the hospital.
History of BHL’s residency program
Initial planning for the residency program began in 2008 in an effort to create a more dynamic, progressive, and academic department. The program was established in 2010 with two residents. In April 2011, the program received full accreditation from ASHP for six years. Once this accreditation was awarded, the program applied for and was awarded pass-through funding by the Centers for Medicare and Medicaid Services (CMS). The provision of CMS funding, coupled with the early success of the program, allowed program expansion from two residents to three in 2012.
Exit interviews with residents completing the program indicated that while they were extremely satisfied with the learning experiences afforded by the program, they did not think the staffing component of the program gave them sufficient confidence as new practitioners. Historically, the staffing component consisted of weekend clinical shifts focused on providing pharmacokinetic consultations and therapeutic drug monitoring. This was coupled with occasional order-entry shifts and sterile i.v. drug preparation in the central pharmacy. These staffing shifts generally occurred on weekdays and necessitated that residents give up a day otherwise spent on their learning experiences. Residents thought that more staffing experiences, particularly experiences arranged in a continuous fashion, would be optimal. Performing individual staffing assignments multiple days in a row would provide the residents an opportunity to focus on and master those tasks, thus building confidence in their participation in centralized functions. Although we attempted to modify the staffing component annually to meet their requests, we believed that further improvements could be made to achieve our goal of creating confident, well-rounded practitioners suitable for the community hospital setting.
Expanding pharmacy services
A goal of the pharmacy department at BHL has always been to emphasize the shared contribution of both distributive and clinical responsibilities in patient care. To that end, all decentralized pharmacists are expected to enter and verify orders for their assigned area. In 2008, the pharmacy department had two decentralized pharmacists and one operating room satellite pharmacy. Since that time, an additional six decentralized pharmacists have been deployed and three oncology satellite pharmacies have been established. These additional services were implemented without including PGY1 residents in the workflow. Established clinical services include pharmacokinetic, anticoagulation, and renal dosing and monitoring; nutrition support; identification of the correct utilization of antimicrobials based on preliminary culture reports; multidisciplinary patient rounding in five ICUs; the provision of drug information; and emergency code response.
A resident research project conducted in 2010–11 indicated a need for enhanced nurse education regarding medication reconciliation within the facility. Subsequently, consistent with a facilitywide initiative to reduce readmission rates among patients with heart failure (HF), the decision was made to involve pharmacists in medication reconciliation for this patient population. Pharmacists were responsible for ensuring the accuracy and clinical appropriateness of patients’ medication lists on admission, performing discharge counseling, and providing a patient-specific medication calendar to enhance compliance. This was accomplished without the addition of staff or the use of PGY1 residents, only via redesigning current workflow. The initial results of this project indicated that the addition of a pharmacist to the multidisciplinary team reduced the rate of HF readmissions by 6% and increased the rate of compliance with quality measures for patient education by 12%. As a result, we decided to commit additional pharmacist resources to medication reconciliation. A PPMI needs assessment performed in 2011 confirmed the need for continued emphasis in decentralizing pharmacy services and reallocating resources to medication reconciliation.
Rationale for expansion of the program
The catalyst for expanding and shifting the existing paradigm of our PGY1 residency program was the ASHP National Pharmacy Preceptors Conference held in August 2012. We continued to ruminate on questions posed at the conference, including, What would happen if our residency program went away?, and Would the department continue to function if the residents were not there? This second question was particularly relevant, given that BHL residents had historically been integrated into the existing clinical functions of the department rather than being used to build the clinical program.
We recognized that residents had met our initial goal of creating a more dynamic academic department. Although we believed the residency had intrinsic value, we acknowledged that demonstrating a quantifiable benefit to others outside the department could be challenging. Our desire was to demonstrate tangible value to the institution that could be clearly communicated to the BHL administration. We elected to expand the program to five residents in an effort to meet the needs of both residents and the department and to support ongoing hospitalwide initiatives. The objectives of the expansion were to
Achieve our long-standing goal of expanding clinical services to the second shift,
Provide the residents with a more real-world staffing experience in a continuous fashion,
Allow for increased pharmacy involvement in medication reconciliation services, and
Provide an opportunity to expand medication reconciliation services to diseases other than HF.
Implementation and logistics
PGY1 learning experiences at BHL had previously been four weeks in duration. Our goal was to maintain the learning experiences while allowing for one resident to be continuously available for second-shift staffing from 10:30 a.m. to 7:00 p.m. Learning experiences would be constructed as five-week blocks in which the five residents would rotate to provide staffing. Thus, on a given week, four residents would be on their learning experiences, and the fifth resident would be performing staffing functions. By establishing a set rotation, we were able to provide continuity for both the learning experiences and the staffing component, as well as meet our previous goal of preventing staffing from interrupting the flow of the learning experiences.
We previously had four second-shift pharmacists in the central pharmacy, with new clinical consultations handled on an as-needed basis. Our desire was to both improve consistency of new second-shift clinical consultations and allow for sufficient personnel to operate the HF program during evening hours. Workflow would be redesigned under the new model to maintain three pharmacists in the central pharmacy to focus on the distributive functions of the department. We then proposed placing a preceptor and a resident at decentralized workstations to provide second-shift decentralized coverage. The decentralized functions would include initiation of clinical pharmacokinetic consultations, admission medication reconciliation, discharge teaching for patients with HF, and order-entry support from decentralized locations. We anticipated that the functions would be approximately 50% related to medication reconciliation, 25% clinical in nature, and 25% distributive in nature.
Barriers and challenges to program expansion
Given that preceptors’ workload would nearly double, preceptor buy in was an initial concern. We met with the preceptors as a group to report findings from the National Pharmacy Preceptors Conference and outline the plans for program expansion. The focus of increasing capacity was to integrate residents into workflow while allowing them more time to practice as pharmacists and contribute to departmental objectives. The staffing function would increase residents’ overall knowledge of departmental operations and foster their sense of independence and ownership. This knowledge of basic departmental functions would ideally shorten the learning curve with each new learning experience. Thus, even though preceptors would be responsible for more residents, the preceptors could focus on the topic of the learning experience rather than orienting residents to pharmacist job functions such as order entry. This increased sense of resident independence helped to alleviate preceptors’ concerns about an increased time commitment.
Because the residency program had been well received within the department, internal resistance to expansion was negligible. Thus, once preceptors had a chance to give their input on expansion, we then went to hospital administration for approval. BHL administration readily agreed to the program’s expansion on the basis of available CMS funding and alignment with both departmental and hospitalwide initiatives. Furthermore, hospital administration and medical staff were complimentary of the program and how it enhanced the perception of the department hospitalwide.
Given the fact that the proposed expansion model was untested, care was taken during the interview process to present the plan in detail to prospective candidates. Candidates were given a schedule template to minimize uncertainty and ensure they understood the proposed process. We reiterated to candidates the fact that we believed this model would provide residents with increased exposure to patients and opportunities to enhance patient counseling skills, develop medication reconciliation skills, and increase their autonomy.
Initially there was a concern that the staffing week could cause an interruption in the learning experiences, particularly for the three residents whose staffing blocks were in the second, third, and fourth weeks of the five-week learning experience blocks. However, by consolidating staffing into one-week blocks rather than a more intermittent staffing schedule from previous years, we were able to enhance continuity for the residents and preceptors by minimizing interruptions during learning experiences.
Preliminary experience with the expansion
The plan for expansion was approved, and we interviewed for five positions for the 2013–14 residency year. While we had always placed a high premium on interpersonal and communication skills, our expansion plan magnified the need to look for individuals with these abilities who were willing to participate in our novel staffing model. Characteristics such as independence, initiative, innovation, and an orientation toward customer service were also emphasized during the interview process. We were forthcoming with candidates about the increased staffing requirements, the need to staff a second shift, and how this aligned with our goal of creating well-rounded pharmacists. Candidates almost universally saw the value of this staffing function as a way to meet their desire for understanding the functions of a clinical, community hospital pharmacist.
All five PGY1 positions were filled via the National Match with candidates who were enthusiastic about our initiative and program. We are currently in the second residency year under the new program structure. Thus far, there has been positive feedback from residents, preceptors, and the department as a whole. A revised three-week orientation process was initiated before the residents’ first learning experience. The orientation was modified to focus on the distributive and medication reconciliation processes to allow the residents to begin functioning in the decentralized capacity during the staffing week of their first learning experience in July.
By having a pharmacist readily available on the units, our first-shift decentralized pharmacists have effectively shaped the demand for pharmacy services among clinical staff. Physicians and nurses have appreciated the extension of this resource to the second shift, and we have received numerous positive comments from these external customers regarding pharmacist availability for medication reconciliation and discharge counseling. Pharmacist participation in admission and discharge medication reconciliation activities has also increased patient satisfaction, evidenced by follow-up surveys conducted by the hospital. More than 95% of patients surveyed remembered talking to a pharmacist, and 96% found the provided medication calendar helpful.
As previously stated, consistent provision of second-shift decentralized pharmacists had previously been a challenge at BHL. The expansion of the residency program allowed this staffing to occur with high-quality, enthusiastic practitioners and no increase in departmental FTEs (PGY1 resident positions do not count in the departmental FTE budget due to CMS pass-through funding). Second-shift decentralized pharmacists also solved the sometimes problematic issue of passing off responsibilities from the first shift to the central pharmacy staff. Upon arrival, the decentralized resident checks in with the first-shift decentralized pharmacists to determine if any problems need to be resolved and to identify patients who are expected to require discharge counseling.
We have determined that medication reconciliation will be an integral and expanding role of the pharmacists at BHL. Having an additional resident on the second shift has allowed us to task the residents with independently managing the established HF program and will ultimately allow the department to expand the clinical program to include additional diseases.
A PGY1 residency program was expanded through the provision of second-shift decentralized clinical services, which helped provide residents with increased patient exposure and enhanced staffing experience.
The authors have declared no potential conflicts of interest.
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