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ADAV 48 ACADEMY OF HEALTH SCIENCES (ARMY) FORT SAM HOUSTON TX--ETC FIG 6/5DECENTRALIZED INPATIENT PHARMACY SERVICE STUDY. PART 8. THE REL--ETC(U)JUL 80 T N RAUCH, b H HARTLEY

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LEVE(HEALTH CARE STUDIES DIVISION REPORT #80-0018

ODECENTRALIZED INPATIENT ZHARMACY SERVICE STUDY.V PARTB.-

O he Relative Merits of Decentralized/Clinicol Pharmacy Services _

by

CPT erry Michael/Rauch NSC, USACOL Brodes H.lHartle MSC. UISA

Health Care Studies DivisionLLAcadenW of Health Sciences

ort Sam Houston, TX 78234

COPTC

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UNITED STATES ARMY HEALTH SERVICES COMMANDFort Sam Houston, TX 78234

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Decentralized Inpatient Pharmacy Service Study - Final ReportPart B (DIPSS) / The Relative Merits of Decentral- Nov 77 to Jul 80ized/Clinical Pharmacy Services s. PERFORMING ORG. REPORT NUMBER

7. AUTHOR(*) S. CONTRACT OR GRANT NUMBER(&)

CPT Terry Michael Rauch, MSC, USACOL Brodes H. Hartley, MSC, USA

9. PERFORMING ORGANIZATION NAME AND ADDRESS i0. PROGRAM ELEMENT, PROJECT, TASK

Health Care Studies Division (HSA-CHC) AREA & WORK UNIT NUMBERS

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IS. SUPPLEMENTARY NOTES

19. KEY WORDS (Continue on revereo side If neceeeay mid idently by block number)

Active Army; Medical; Management; Survey; Hospital Pharmacy; Decentralized UnitDose Systems; Inpatient; Clinical Pharmacy

M[ ASSTRACT (VWE e m ernw e n.oommy and Mentyip by NMock numbr)

"%The purpose of this research was to identify the functional requirements andacceptability of decentralized/clinical pharmacy services by health care pro-fessonals. In June 1979, a random sample of nurses (o 18801, physicians.463'and pharmacists-( --t4A44 ssigned to 35 Amy Medical Treatment Facilitiesin the United States were requested to complete surveys designed to assess theirperceptions of various pharmacy support activities. The results shoved thatpharmacists rate as most important job tasks which require providing pharmaceu-tical information to health ian aranf4inftnlC ln rJnhrn!ttlcthaff --

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conmunication is necessary to promote positive attitudes toward specific phar-maceutical tasks.Health care workers are most ddssatsfled with pharmacy servicin which the pharmacist provides information to the professional staff and drugdischarge consultation. The five clinical areas perceived to have the greatestdemand for decentralized/clinical pharmacy support are Medical ICU, SurgicalICU, Oncology, Cardiology, and Pediatrics.

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SUMM4ARY

Under existing Army# pharmacy programs, the preparation of parenteral,solutions has been centralized and unit dose drug distribution systemsestablished at numerous Army inpatient facilities. However, there areaccompanying problems with centralized unit dose such as missing medica-tions (Pang and Grant, 1975), timely response and failure to commnunicatenew or changed medication orders, patient discharges and patient transfers(Jackson, Anderson and McGuire, 1978). Furthermore, even though centralizedunit dose system have resulted in some increased utilization of pharmacists'professional training, experience and knowledge, the Army pharmacist all tooften remains an under-challenged and under-utilized memb~er of the patientcare team.

Previous studies in civilian hospitals have found that selectivedecentralization of unit dose medications from inpatient satellite pharma-cies, when compared to centralized systems, has helped to overcome problemsin responsiveness and commnunication, enhance rational drug therapy andreduce medication and personnel costs (Pang and Grant, 1975; John, Burkhartand Lamy, 1976; Vorio, 1972). Furthermore, the physical proximity of de-centralized pharmacies to patient care areas may enhance rapport betweenpharmacists and other health care professionals, and facilitate the develop-ment of patient or therapy-related activities. Hence, decentralized unitdose services from satellite pharmacies in support of a specific clinicalarea should be conducive to the development of clinical pharmacy. However,justification for establishing such services in Armly t4TFs are yet to bedemonstrated. There is a current need to identify the functional require-ments and acceptability of decentralized/clinical pharmacy services by healthcare professionals.

In June 1979, a random sample of nurses (n = 1000), physicians (n =700)and pharmacists (n = 145), assigned to 35 Army MTFs in the United States wererequested to complete surveys regarding their perceptions of various pharmacysupport activities.

From the results of the present study' it can be concluded that:

A. Pharmacists rate as most important those tasks which require pro-viding information to health care professionals. Major importance isattached to tasks such as answering q uestions by.Dhysicians and nurses, pro-vi ding information on drug dosage and providIng Information about a-drug thats new or unfamiliar.

B. Close pharmacist/staff communication is necessary to promote posi-tive values toward specific pharmaceutical tasks.

C. Nurses, physicians and pharmacists are most satisfied with pharmacyservices in which the pharmacist provides information to the professionalstaff and most dissatisfied with patient education in medication complianceand drug discharge consultation. The dissatisfaction is more than likelythe result of pharmacists not having adequate time to provide patienteducation and discharge consultation services.

D. Unit dose support has little impact on the perceptions of nurses,physicians and pharmacists on the importance of task characteristics ofrcinical pharmacy services.

E. Decentralized pharmacy support has little effect on the percep-tions of nurses, physicians and pharmacists in determining which patientcare activities the pharmacist should perform. On the other hand, healthcare professionals supported by decentralized services express significantlygreater agreement that decentralized/clinical pharmacy services should beimplemented or expanded in Army MTFs.

F. The five clinical areas perceived to have the greatest demand fordecentralized/clinical pharmacy support are Medical ICU, Surgical ICU,Oncology, Cardiology and Pediatrics.

TABLE OF CONTENTS

Page

SUMM9ARY.................. .. ...... ..... .. .. .. .. .....

TABLE OF CONTENTS........ .... . ... . .... .. .. .. .. .....

LIST OF TABLES. ... ........ ........ ........ vi

INTRODUCTION .. ...... ........ ........ ......

METHOD. .. ......... ........ ........ .... 2

RESULTS .. .. ......... ........ ........... 3

DISCUSSION. ... ........ ........ .......... 5

CONCLUSIONS .. ... ........ ........ ......... 8

RECOMMENDATIONS. .. ...... ........ ............ 8

REFERENCES. ... ........ ........ .......... 9

TABLES .. ...... ........ ......... ....... 11

APPENDIX A .. ..... ......... ........ ..... 31

DISTRIBUTION. ... ........ ........ ......... 63

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LIST OF TABLES

Table P age

1 Demographic Characteristics of Professional Groups: Nurses,Physicians and Pharmacists .. .. . .. ... .. ... ...... 12

2 Analysis of Variance for Demographic Characteristics ofProfessional Groups .. .. ... .. ... .. ... .. .... 13

3 Perceived Imp~ortance of Clinical Pharmacy Tasks By Nurses,Physicians, and Pharmacists. .. . ... .. ... .. ..... 14

4 Perceived Importance of Clinical Pharmacy Tasks BetweenRespondents Whose Pharmacy Service Provides the IndicatedTask (Group 1) and Respondents Whose Pharmacy Service DoesNot Provide the Task (Group 2). .. .. ... .. ... ...... 16

5 Nurse, Physician and Pharmacist Satisfaction with CurrentPharmacy Services. .. ... .. ... .. ... .. ..... 18

6 Perceptions of Nurses, Physicians and Pharmacists on TaskCharacteristics of Clinical Pharmacy Services. .. . ....... 22

7 Analysis of Covariance*: The Effect of Professional Groupand Unit Dose Support on the Perceptions of Task Characteris-tics of Clinical Pharmacy Services .. .. . .. ... .. .... 24

8 Analysis of Covariance: The Effect of Professional Group andDecentralized Pharmacy Support on the Perceptions of ClinicalPharmacy Services. .. .. ... ... .. ... .. ..... 26

9 Clinical Areas with the Greatest Demand for Decentralized/Clinical Pharmacy Service as Perceived by Professional Groups:Nurses, Physicians and Pharmacists .. .. . .. ... .. .... 28

10 Clinical Areas with the Greatest Demand for Decentralized/Clinical Pharmacy Service as Perceived by Respondents HavingPrevious Exposure to Decentralized/Clinical Service VersusRespondents Not Having Exposure to Decentralized/ClinicalService. .. . .. ... .. ... .. ... .. ... ..... 29

11 Clinical Areas with the Greatest Demand for Decentralized/Clinical Pharmacy Service as Perceived by MEDCEN and MEDDACRespondents .. .. ... .. ... .. ... .. ... ...... 30

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I. INTRODUCTION.

A. Purpose. The present study is the second part of Phase I: Decertr,1-ized Inpatient Pharmacy Service Study. The primary objectives of this part c+

the study were:

(1) To determine the level of nurse, physician and pharmacist satisfac-tion with pharmacy services now provided in Army MTFs.

(2) To determine the perceptions of nurses, physicians and pharmacistsregarding decentralized/clinical pharmacy services in Army MTFs.

(3) To identify pharmacist activities which should be included in a de-centralized/clinical pharmacy service.

(4) To identify the clinical areas with the greatest demand for decen-tralized/clinical pharmacy support as perceived by nurses, physicians and phar-macists.

B. Background - Literature Review.

(1) Under existing Army Pharmacy proqrams, the preparation of parenter-al solutions has been centralized and unit dose drug distribution systems estab-lished at numerous Army inpatient facilities. Over 75% of these inpatient fa-cilities dispense medications on a unit dose basis (Hartley and Rauch, 1980).Nevertheless, centralization of unit dose has not proven to be a panacea. Thereare accompanying problems such as missing medications (Pang and Grant, 1975),timely response and failure to camunicate new or changed medication orders,patient discharges and patient transfers (Jackson, Anderson and McGuire, 1978).Furthermore, even though centralized unit dose systems have resulted in saneincreased utilization of pharmacists' professional training, experience andknowledge, the Army pharmacist all too often remains an under-challenged andunder-utilized member of the patient care team.

(2) Previous studies in civilian hospitals have found that selectivedecentralization of unit dose medications fran inpatient satellite pharmacies,when compared to centralized systems, has helped to: (a) overcome problems inresponsiveness and communication (Pang and Grant, 1975); (b) enhance rationaldrug therapy (John, Burkhart and Lamy, 1976); and (c) reduce medication andpersonnel costs (John, et. al., 1976; Yorio, 1972).

(3) Pharmacy personnel activities and labor costs in decentralized andcentralized unit dose drug distribution systems were compared in a study byJohn, Burkhart and Lamy (1976). The results strongly indicated an overall dif-ference in the activities between decentralized and centralized unit dose ser-vices. More time was spent in therapy-related activities by pharmacists prac-ticinq in decentralized areas. In addition, nonpharmacist personnel in the de-centralized unit dose systems spent significantly more time preforming dispens-ing functions than did their counterparts in centralized unit dose areas. Thefindings suggest that the physical proximity of decentralized pharmacies to pa-tient care areas may enhance rapport between pharmacists and other health careprofessionals, and facilitate the development of patient or therapy-related ac-tivities. Moreover, since there was a significantly greater proportion of ther-apy-related activities in decentralized areas, decentralization of unit dosemay be more conducive to the development of clinical-patient care pharmacies.

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(4) Previous studies have described the activities of patient care phar-macists practicing in varied settings, such as rural facilities (Curtiss andWertheimer, 1978), pediatric medical rounds (Klotz and Steffens, 1976), mentalhealth services (Stimmel, 1977; Dugas, Cardoni and Pierpaoli, 1975), hyperten-sive clinics (McKenney, Slining and Hendersen, 1973), emergency medicine (Elen-baas, Waeckerle and McNabney, 1977), and primary health care (Johnson and Tuch-ler, 1975). Although it is evident that pharmacists are active components inthe previous patient care programs, the ultimate success of clinical pharmacywill be dependent upon the attitudes of nurses, physicians and patients towardthe clinical pharmacist and the services offered (deLeon, 1971; McKay and Jack-son, 1976). Previous studies have reported that close physician pharmacistcommunication and cooperation were necessary to promote the development of pos-itive attitudes toward specific pharmaceutical services (Knapp, Knapp and Ed-wards, 1969; Kapnick, Blissitt and Rabe, 1970; Smith, Sorby and Sharp, 1975;Wallace and Kradjan, 1977; Bernstein, Klett and Jacoby, 1978). Furthermore,patients exposed to increased pharmacist communication about drug therapy ex-perienced a substantial improvement in attitude toward pharmacy services (Yel-lin and Norwood, 1974; Norwood, 1975). Helling, Hepler and Jones (1979) repor-ted that a group of patients who had at least one clinical pharmacy encounterin a family practice clinic demonstrated significantly more satisfaction withthe overall quality of health care they received from the clinic than did acontrol group which had not received any clinical pharmacy services. The studynot only showed more patient satisfaction in overall health care, but alsogreater satisfaction in pharmacy-related areas, H3wever, the concept of phar-macists providing drug information and other patient care activities has notbeen entirely accepted. Previous studies have been conducted to evaluate phy-sicians' perceptions of drug information resources (Smith, Sorby and Sharp,1975; Harelik, Johnston, Rivers and Ryan, 1975). The results showed that phy-sicians consistently rated professional journals and the Physicians' Desk Refer-ence as "good" sources of drug information, but rated the pharmacist as a "poor"source. Moreover, pharmacists were seldom considered as sources of drug infor-mation which would directly affect patient therapy. In a study with contrastingresults, Hamm et. al. (1973) reported that 82% of the sampled physicians favoredusing the pharmacist as a continual source of drug information.

(5) Pharmacists practicing in patient care areas and selected decentral-ization of unit drug services are of particular interest because of the potentialbenefit to patient care and professional growth of pharmacists. However, justi-fication for establishing such services in Army MTFs are yet to be demonstrated.

II. METHOD.

A. Subjects. Survey respondents consisted of a random sample of nurses(N = 739), physicians (N = 313) and pharmacists (N = 153) assigned to 35 ArmyMedical Treatment facilities in the United States.

B. Procedure. Information was obtained by means of survey questionnairesseparately developed for nurses, physicians and pharmacists (see Appendix A).Questionnaires were pre-tested for clarity and content validity in a pilot test.Demographic information was requested and all other responses were arranged ina 7-point Likert-type format. Each survey was addressed to the subject person-ally and mailed in June of 1979. After completion, respondents were instructedto return the surveys using a government franked return address sheet,

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III. RESULTS.

A. Demographic Characteristics of Professional Groups; Nurses, Physiciansand Pharmacists. Preliminary analyses were conducted to control for age, yearsof military service and length of time assigned to MTF, Table I presents inter-cell means and standard deviations for these variables, and Table II shows theresults of a one-way ANOVA. Inspection of the analyses in Table II reveals nosignificant difference between groups as a function of age, whereas significantdifferences were found for years of military service F(2, 1183) = 4.86, p <.008,and length of time assigned to 'MTF FC.2, _U871 = 12.49, p <.OQI. Between groups,nurses had the greatest number of-years in military service, x = 9.06, and thegreatest length of time assigned to MTF, 3-= 43.40 months. Pharmacists had theleast number of years of military service; = 7.36, while physicians the short-est length of time assigned to MTF, X = 26.81 months.

B. Perceived Importance of Clinical Pharmacy Tasks by Professional Groups:Nurses, Physicians and Pharmacists. Table III presents the results of a one-way ANOVA using years of military service and length of time assigned to MTF ascovariates and perceived importance of the selected task as the dependent mea-sure. On each selected task, the pharmacists' rating of perceived importancewas higher (i.e., judged more important) than either nurses' or physicians'.Furthermore, on every task with the exception of one, physicians' ratings werelower than pharmacists' and nurses'. Significant group differences regardingthe relative importance of pharmacy tasks were achieved for every task exceptfor: (a) participation in the establishment of a drug formulary, (b) compound-ing IV additives and (c) answering questions asked by physicians and nurses.The five most important tasks as perceived by each group were identical althoughonly one, answering questions asked by physicians and nurses, was mutuallyranked as the most important. Table III also depicts the results of a Scheffeprocedure on pairs of group means on each clinical pharmacy task. Significantdifferences (F values) for all possible pairs of group means were found for altclinical pharmacy tasks with the exception of providing information about adrug that is new or unfamiliar. On this task, nurses and pharmacists did notdiffer from one another but both differed from physicians,

C. Perceived Importance of Clinical Pharmacy Tasks Between RespondentsWhose Pharmacy Service Provides the Indicated Task (Group 1) and RespondentsWhose Pharmacy Service Does Not Provide the Task (Group 2). A comparison ofGroups 1 and 2 indicated no significant difference as a function of age, yearsof military service, or length of time assigned to MTF. Means, standard devia-t'ons and the results of univariate F tests are depicted in Table IV. Signifi-cant group differences were found for every task with Group 1 (respondentswhose pharmacy service provides the indicated task) rating the task as moreimportant than their counterparts. The largest discrepancies between groupsoccurred with participation on the emergenc team, F(1, 971) = 172.17, p< .001,maintaining drug therapy information on patients hl, 978) = 127.81, p< .001,compounding IV additives F(1, 1051)= 106,80, p<.001, and conduct follow-upobservation of patients o determine efficacy of drug thera F I, 1033)=100.98, p< .001.

D. Nurse, Physician and Pharmacist Satisfaction with Current PharmacyServices. Each of the 22 dependent measures concerning satisfaction with cur-rent pharmacy services was analyzed with a one-way analysis of covariance(ANCOVA). When the analysis revealed significant differences between the mean

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scores of professional groups, pairs of groups were compared using a Scheffeprocedure. Table V shows the means, standard deviations and F tests for eachsatisfaction item. Significant professional group differences were found onevery item with the exception of accuracy of patient medication profiles, in-formation on the pharmacy patient profile, hours of operation of the pharmacyservice and the unit dose drus distribution system.

E. The Effect of Professional Group (Nurse, Physician and Pharmacist) onthe Perceptions of Task Characteristics of Clinical Pharmacy Services. Theresults from a one-way ANCOVA are presented in Table VI, Significant differ-ences between professional groups were found for every task when years of mil-itary service and length of time assigned to MTF were controlled for. In-spection of intercell means and standard deviations reveal that pharmacists re-corded higher scores than nurses and physicians on all but two task character-istics, while physicians (without exception) obtained the lowest scores onevery task.

To determine which mean scores significantly differed on each task char-acteristic, an a posteriori contrast test was applied to the data. The resultsof a Scheffe procedure on each task characteristic is depicted in Table VI.Statistically significant differences on all possible pairs of group means werefound for every task characteristic of clinical pharmacy services with the ex-ception of pharmacist should serve on the hospital emergency team (physicians <nurses, pharmacists), pharmacist should serve the druq information needs ofthe medical and nursing staffs (physicians < nurses, pharmacists) and pharma-cist should check the physician's drug order prior to administration of drugto patient (pharmacist > nurses, physicians). Overall, respondents perceivedthe most important/agreeable task characteristic concerned the pharmacist serv-ing the drug information needs of the medical and nursing staffs.

F. The Effect of Professional Group and Unit Dose Support on the Percep-tions of Task Charcteristics of Clinical Pharmacy Services. Table VII presentsthe results of a two-way ANCOVA using years of military service and length oftime cssigned to MIF as covariates. Dependent variables include task charac-teristics associated with clinical pharmaceutical services and independent var-iables were professional group (nurses, physicians and pharmacists) and unitdose support (i.e., whether or not the respondents' ward/service was supportedby unit dose). Inspection of the data shows significant differences on alltask characteristics as a function of professional group. In contrast, signif-icant differences for professional groups supported by unit dose versus thosenot supported by unit dose were obtained for only two tasks: pharmacist shouldmonitor each patient drug therapy regimen by maintaining a patient medicationprofile F(1, 1055) = 28.35, p <.001, and pharmacist should check the physician'sdrug order prior to administration of drug to patient F(1, 1055) = 8.95, p <.001.On these two tasks, respondents supported by unit dose had a more favorable re-sponse to that task than those not supported by unit dose services. There was asignificant interaction for one task: pharmacist should serve the drug infor-mation needs of the medical and nursing-staffs F(2, 1055) = '3.74, p <.024. Closeexamination of the cell means in Table VII for this task reveals that there waslittle difference between nurses and pharmacists supported by unit dose versusthose not supported by unit dose. On the other hand, cell means for physicianswere much larger in the unit dose support condition as compared to the no unitdose support, (6.42 and 6.13, respectively).

G. The Effect of Professional Group and Decentralized Pharmacy Support onthe Perceptions of Clinical Pharmacy Services, The analysis consisted of anANCOVA with years of military service and length of time assigned to MTF ascovariates and perception of task characteristics-Of clinical pharmacy servicesas the dependent variable. Independent variables were professional group andtype of pharmacy support (i.e., whether the respondents were supported by adecentralized or centralized pharmacy). Table VIII presents intercell meansand the results of a two-way ANCOVA. Examination of the cell means reveal sig-nificant professional group differences on every task characteristic, yet sig-nificant differences between the type of pharmacy support, (decentralized ver-sus centralized) were obtained for only two dependent measures; the Arm shouldinstitute decentralized or satellite pharmacy service in its hospitals F(1, 1055)44.17, p < .001 and the Army should implement or expand clinical pharmacy practicein its hospitals F(i, 1055) = 8.89, p .003. On both measures, cell means weresignificantly larger for the respondents supported by decentralized services.There was no significant professional group x type of pharmacy support interac-tion on any of the dependent measures.

H. Clinical Areas with the Greatest Demand for Decentralized/ClinicalPharmacy Services as Perceived by Professional Groups: Nurses, Physicians andPharmacists. Significant differences between professional groups were found foreach clinical area investigated. Intercell means, standard deviations and theresults of a one-way ANCOVA (years of military service and length of time assignedto MTF were covariates) are presented in Table IX. Physicians consistently ratedthe need for decentralized/clinical pharmacy service lower for each clinical areathan did nurses and pharmacists. Overall, the five clinical areas perceived tohave the greatest demand for decentralized/clinical pharmacy service were MedicalIntensive Care Unit (ICU), Surgical ICU, Oncology, Pediatrics and Cardiology.

I. Clinical Areas with the Greatest Demand for Decentralized/Clinical Phar-macy Service as Perceived by Respondents Having Previous Exposure to Decentral-ized Service versus Respondents Not Having Exposure to Decentralized Service.Comparison of the exposure and no exposure groups revealed no significant differ-ences as a function of age, years of military service and length of time assignedto MTF. Table X shows intercell means, standard deviations and the results of aone-way ANOVA. Clinical areas with the highest means (i.e., perceived to havethe greatest demand for decentralized/clinical pharmacy) were Medical ICU, Surgi-cal ICU, Oncology, Cardiology and Pediatrics. Of the five clinical areas previ-ously stated, significant group differences were obtained for Medical ICU F(1,1036) = 5.51, p< .019, Cardiology F(1, 1018) = 5.72, p<.017, and Pediatrics F(1,1025) = 5.33, p< .021.

J. Clinical Areas with the Greatest Demand for Decentralized/Clinical Phar-macy Service as Perceived by MEDCEN and MEDDAC Respondents. Comparison of MEDCENand MEDDAC respondents showed no significant differences as a function of age,years of military service, or length of time assigned to MTF. Table XI presentsintercell means, standard deviations and the results of a one-way ANOVA. Inspec-tion of the means in Table XI reveal that Medical ICU, Surgical ICU, Oncology,Cardiology and Pediatrics are the five clinical areas perceived to have thegreatest demand for decentralization and clinical pharmaceutical services.

IV. DISCUSSION.

A. Perceived Importance of Clinical Pharmacy Tasks by Professional Groups:Nurses, Physicians and Pharmacists, Of primary interest was the general finding

that pharmacists rate as most important those tasks which require providing in-formation to members of the hospital staff, in comparison with all other phar-macy tasks. Pharmacists tend to attach major importance to tasks that requireproviding information such as answering questions by physicians and nurses,providing information on dru g dosage and pmrvidin$ information about a drug~tnat is new or unfamiliar. Although there were significant differences etweenprofessional groups regarding the relative importance of these tasks, nursesand physicians tended to agree that these tasks were the most important in thepharmacist's role.

Pharmacists believe that their follow-up observation of patients to deter-mine drug efficacy and possible adverse reactions and participating on the emer-gency team to be important, although less important than other tasks. Physiciansand nurses disagree significantly with pharmacists regarding the importance ofthese activities by rating them as neutral to unimportant. Comipounding intra-venous (IV) additives and helping to establish a drug formulary is seen as beinga moderately important function of pharmacists equally by nurses, physiciansand pharmacists.

B. Perceived Importance of Clinical Pharmacy Tasks Between RespondentsWhose Pharmacy Services Provides the Indicated Task (Group 1) Versus RespondentsWhose Pharmacies Do Not Provide the Task (Group 2). Close pnarmacist/staffconmunication necessary to promnote the development of positive values towardspecific pharmaceutical tasks is strongly supported by the present findingssince significant group differences were found for every task.

The group whose pharmacy service provides the task had significantly great-er means when compared to their counterparts. Furthermore, tasks with thegreatest means were those where the pharmacist provided information about drugsor answered questions by physicians and nurses. Mean scores for respondentswhose pharmacy service did not provide the service were largely nonconinitalwith the exception of one -- providing information about a drug that is new orunfamiliar -- which was perceived to be the most important. Overall, respondentshaving exposure to pharmacists performing a given task rated that task signifi-cantly more important than their less knowledgeable counterparts.

C. Nurse, Physician and Pharmacist Satisfaction with Current Pharmacy Ser-vice. These results clearly demonstrate significant professional group differ-ences on 18 of 22 pharmacy satisfaction measures. Nurses are most satisfiedwith the amount of drug information provided in response to physician and nurseneeds, physicians with the pharmacists' availability to provide professionalservices to other members of the health care team, and pharmacists with theavailability of emergency drugs for use by the health care team. On the otherhand, nurses and pharmacists are most dissatisfied with drug consultations bythe pharmacist to orient the patient to proper methods and effects of takingtheir medication after dischargie and the education of patients and families inmedication compliance respectively. -nterestingly, the lowest physician meansare more indicative of indifference (neutral ratings) rather than dissatisfactionwith selected pharmacy services. Overall, respondents were most satisfied withservices in wtrtch the pharmacist provides information to the professional staffand most dissatisfied with patient education in medication compliance and drugdischarge consultation.

0. The Effect of Professional Group and Unit Dose Support on the Perceptionsof Task Characteristics of Clinical Pharmacy Services. The perceptions of nurses,physicians and pharmacists significantly differed on every task characteristic.

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However, all three professional groups reported most agreement with the taskcharacteristic of the pharmacist ser'~ing the drug information needs of the medi-cal and nursing staffs-.

P r-ofessionals supported by unit dose differed from those not supported byunit dose on only two task characteristics. Furthermore, the only significantinteraction was found for pharmacists should serve the drug information needs ofthe medical and nursing staffs and was the result of a relatively large differ-ence between physicians supported by unit dose versus physicians not supportedby unit dose. Overall, it must be concluded that unit dose support has verylittle impact on the perceptions of nurses, physicians and pharmacists on theimportance of task characteristics of clinical pharmacy services.

E. The Effect of Professional Group and Decentralized Pharmacy Support onthe Perceptions of Clinical Pharmacy services. Clearly, nurses, physicians andpharmacists perceive the importance of the task characteristics presented inTable VIII quite differently. Professionals supported by a decentralized phar-macy service significantly differed from professionals supported by a central-ized pharmacy service on only two task characteristics. -sexpected, profes-sionalis supported by decentalized services expressed significantly greateragreement that decentralized or satellite pharmacy services and clinical phar-macy practice should be expanded or implemented in Army MTFs. This finding isconsistent with the notion that the physical proximity of decentralized pharma-cies to patient care areas enhances rapport between pharmacists and other healthlcare professionals and facilitates the development of patient care-related ac-tivities by the pharmacist. Yet, on selected task characteristics there was nosignificant difference as a function of the type of pharmacy support. This find-ing appears to be in conflict with the earlier finding showing that acceptanceof pharmacists' practicing patient care activities is a function of decentralizedpharmacy support. One possible explanation for this discrepancy is the healthcare professionals supported by decentralization significantly favor the clinicalpharmacy concept, but are not in agreement as to which of the patient care ac-tivities the pharmacists should perform.

F. Clinical Areas with the Greatest Demand for Decentralized/Clinical Phar-macy Services. The findings of the present study strongly indicate that MedicalICU and Surgical ICU are the two clinical areas which have the greatest demandfor decentralized/clinical pharmacy support. Furthermore, when the sample wasbroken down by respondents having previous exposure to decentralized serviceversus not having such exposure, Medical ICU and Surgical ICU were rated as beingthe most desirable for decentralized/clinical support. Responses were also bro-ken downi by MEDCEN versus MEDDAC and revealed similar results: Medical ICU andSurgical ICU obtained the largest means indicating the highest priority of need.

The fact that respondents perceive Medical ICU and Surgical ICU to be theareas in greatest need for decentralized/clinical pharmacy support may resultfrom the need to provide as much effective professional support to these highcare areas as possible. Decentralization of Medical and Surgical ICUs may beperceived to give the pharmacist closer proximity to the patient, physicians andICU nurses thereby increasing the pharmacists' clinical effectiveness and pro-viding more efficient logisti cal support to the nurse and patient.

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V. CONCLUSIONS,

It is concluded that;

(a) Pharmacists rate as most important those tasks which require providinginformation to health care professionals. Major importance is attached to taskssuch as answering questions asked b physicians and nurses, providing informa-tion on drug dosage, and prOvfding information about a drug that is new or un-familiar.

(b) Close pharmacist/staff communication is necessary to promote positivevalues toward specific pharmaceutical tasks.

(c) Nurses, physicians and pharmacists are most satisfied with pharmacy ser-vices in which the pharmacist provides information to the professional staff andmost dissatisfied with patient education in medication compliance and drug dis-charge consultation. The dissatisfaction is more than likely the result ofpharmacists not having adequate time to provide patient education and dischargeconsultation services.

(d) Unit dose support has little impact on the perceptions of nurses, physi-cians and pharmacists on the importance of task characteristics of clinicalpharmacy services.

(e) Decentralized pharmacy support has little effect on the perceptions ofnurses, physicians and pharmacists in determining which patient care activitiesthe pharmacist should perform. On the other hand, health care professionalssupported by decentralized services express significantly greater agreementthat decentralized/clinical pharmacy services should be implemented or expandedin Army MTFs.

(f) The five clinical areas perceived to have the greatest demamd for decen-tralized/clinical pharmacy support are Medical ICU, Surgical ICU, Oncology,Cardiology, and Pediatrics.

VI. RECOMMENDATIONS.

a. Recommend that an abstract of the present study be made available to allArmy pharmacists and health care planners.

b. Recommend a pilot study to test a proposed decentralized unit dose andclinical pharmacy program at Brooke Army Medical Center.

8

REFERENCES

1. Bernstein, L.R., Klett, E.A. and Jacoby, K.E., "Physicians" Attitudes Towardthe Use of Clinical Pharmaceutical Services in Private Medical Practice," Ameri-can Journal of Hospital Pharmacy 35: June, 1978.

2. Curtiss, Frederick Rand and Wertheimer, Albert I., "A Project to ImplementClinical Pharmacy Practice in Rural Environments," Public Health Reports 93(l):January-February, 1978.

3. de Leon, R.F., "Clinical Pharmacy at the University of California," Journalof American Pharmaceutical Association 11: February, 1971.

4. Dugas, James E., Cardoni, Alex A., and Pierpoali, Paul G., "PharmacistsShould Serve on Psychiatric Patients' Units," Hospitals 49: September 16, 1975.

5. Hamm, M.N. et. al., "Survey of Physicians' Drug Information," Journal ofAmerican Pharmaceutical Association 13: July, 1973.

6. Harelik, J.H., Johnston, P.M., Rivers, N.P. and Ryan, M.R., "Pharmacist andPhysician Evaluation of Drug Information Services," American Journal of HospitalPharmacy 32: June, 1975.

7. Hartley, Brodes H. and Rauch, Terry M., "Decentralized Inpatient PharmacyService Study: Chief of Pharmacy Survey," Health Care Studies Division, Academyof Health Sciences (HCSO Report No. 80-001), June, 1980.

8. Helling, D.K., Hepler, C.D., and Jones, M.E., "Effect of Direct ClinicalPharmaceutical Services on Patients' Perceptions of Health Care Quality," Ameri-can Journal of Hospital Pharmacy 36: March, 1979.

9. Hynniman, C.E. et. al., "A Comparison of Medication Errors Under the Univer-sity of Kentucky Unit-Dose System and Traditional Drug Distribution Systems inFour Hospitals," American Journal of Hospital Pharmacy 27: October, 1970.

10. Jackson, J.C., Anderson, R.K., and McGuire, R., "Decentralized PharmacistConcept Solves Unit Dose Problems," Hospitals 52: April 16, 1978.

11. John, Gerald W., Burkhart, Vincent de Paul, and Lamy, Peter P., "PharmacyPersonnel Activities and Costs in Decentralized and Centralized Unit Dose DrugDistribution Systems," American Journal of Hospital Pharmacy 33: January, 1976.

12. Johnson, R.E. and Tuchler, R.J., "Role of the Pharmacist in Pharmacy HealthCare," American Journal of Hospital Pharmacy 32: February, 1975.

13. Kapnick, P.L., Blissitt, C.W., and Rabe, C.C., "Present and Future PharmacyPractice," Journal of American Pharmaceutical Association 10; August, 1970.

14. Klotz, Roger and Steffens, Susan, "Improved Pharmacy Services Through Phar-macist Participation in Medical Rounds," American Journal of Hospital Pharmacy33: April, 1976.

9

15. Knapp. D.., Knapp, D.A., Edwards, J.D, et,al,, "The Pharmacist as Perceivedjy Physicians, Patrons and Other Pharmacists," Journal of American PharmaceuticalAssociation 9: February, 1969.

...*,,.P. and Jackson, R.A., "Attitudes of Primary Care Physicians TowardUtilization c f the "armacist Versus the Physician's Assistant in Patient Care,"American Journal of Pniarmacy 148: November-December, 1976.

17. McKenney, J.M., Slining, J.M., Hendersen, H.R. et. al., "The Effect ofClinical Pharmacy Services on Patients With Essential Hypertension," Circulation47: November, 1973.

18. Norwood, G.J., "Impact of a Clinical Pharmacist's Emphasis on Patient Com-munication on the Patients' Attitude Toward Pharmacy," Drug Intelligence andClinical Pharmacy 9: November, 1975.

19. Pang, Fred and Grant, Josephine A., "Missing Medications Associated WithCentralized Unit Dose Dispensing," American Journal of Hospital Pharmacy 32:November, 1975.

20. Smith, G.H., Sorby, D.L. and Sharp, L.V., "Physician Attitudes Toward Drug:nformation Resources," American Journal of Hospital Pharmacy 32: January, 1975.

21. Stimmel, Glen L., "Clinical Pharmacy Services in Mental Hea.... Facilities,"itals 51: January 1, 1977.

22. Wallace, D. and Kradjan, W., "Physicians' Opinions of Pharmacists as Dis-pensers of Patient Medication Information," Journal of the American Pharmaceu-tical Association 17: June, 1977.

23. Yellin, A.K. and Norwood, G.J., "The Public's Attitude Toward Pharmacy,"ourl of ,t:e American Pharmaceutical Association 14: February, 1974.

24. Yorio, D. et. al., "Cost Comparison of Decentralized Unit Dose and Tradi-tioral Pharmacy Services in a 600-Bed Community Hospital," American Journal ofHospital Pharmacy 29: November, 1972.

In

TABLES

Table I

Demographic Characteristics of Professional Groups:

Nurses, Physicians and Pharmacists

Demographic Nurse Physician PharmacistVariable (n =739) (n 313) (ni 153)

Standard Standard StandardAge (yrs) Mean Deviation Mean Deviation Mean Deviation

34.89 10.56 35.64 7.64 34.91 8.55

Standard Standard StandardMilitary Mean Deviation Mean Deviation Mean Deviation

Service (yrs)9.06 6.62 8.29 6.69 7.36 5.70

Standard Standard StandardLength of Time Mean Deviation Mean Deviation Mean Deviation

Assigned toMTF (months) 43.40 58.61 26.81 21.24 35.93 39.34

12

Table II

Analysis of Variance for DemographicCharacteristics of Professional Groups

Demographic Nurse Physician PharmacistVariable Mean SD Mean SD Mean SD F SIG

Age (yrs) 34.89 10.56 35.64 7.64 34.91 8.55 - ns*Military 9.06 6.62 8.29 6.69 7.36 5.70 4.86 .008

Service(yrs)

**Length of 43.40 58.61 26.81 21.24 35.93 39.34 12.49 .001Time As-signed toMTF (months)

* df = (2, 1183)

** df = (2, 1187)

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03

APPEDIX A

- - LIN

DEPARTMENT OF THE ARMYACADEMY OF HEALTH SC!ENCES, UNITED STATES ARMY

FORT SAM HOUSTON. TEXAS 78234

S: 16 July 1979

HSPA-C 25 June 1979

SUBJECT: Decentralized Inpatient Pharmacy Service Study

1. in response to a request from the Commander, Health Services Command,the Health Care Studies Division is undertaking a study of the feasibility

and potential utility of a decentralized inpatient pharmacy service.

2. Survey instruments have been developed to obtain data for analysis.Separate questionnaires have been designed for physicians, pharmacists

and nurses. Your name has been randomly selected to constitute the testpopulation. Therefore, your cooperation and assistance is solicited.

3. In support of this pilot study, you are requested to complete theattached questionnaire. When you have completed the questionnaire, foldand staple in accordance with the instructions provided on the last pageand place it in the mail. It is requested that you mail your question-

naire not later than 16 July 1979. You may be assured that your responsesand comments shall remain anonymous.

I Inc 1 E. H ERTZ M.ea Coll MC

nuty Chief of StaffProfessional Activities

,'P Form 15'-2 (0T[')

32

PHARMACY SERVICE SATISFACTION QUESTIONNAIRE FOR NURSES

In an effort to provide the beat health care possible we are askingyou to take a few minutes to respond to the following questions and

items. The questionnaire is anonymous; you are not to identify

yourself. In this respect, we ask that you state your honestopinion on all questions and items. The information provided willbe held in the strictest confidence.

PART I

1. Age: 2. Sex: Male __ Female

3. Military __ Civilian

4. Rank/Grade

5. Duty title MOS

6. Specialty

7. In what year did you pass your boards

8. Years military/government service

9. Years civilian hospital experience

10. Are you assigned/employed at a MEDCEN MEDDAC

11. On what clinic, ward or service do you spend the majority of yourtime delivering health care

12. How long have you been assigned/employed with your presentMEDCEN/MEDDAC

13. How long have you been assigned/employed with your present

clinic/ward/service

14. Is your ward/service supported by a unit dose distribution system

yes no

15. Is your ward/service supported by a decentralized or satellitepharmacy?

yes no

15.1 If yes, are other wards or services supported by the same

decentralized or satellite pharmacy?

yes no

33

5.2 If yes, please list the other wards/services?

16. Have you been assigned/employed at other hospitals which provide

decentralized or satellite pharmscy services

yes no

17. Please indicate the average amount of time that you spend in theperformance of the following tasks per day (give your bestestimate in minutes).

Task Time

Prepare doses for administration

Administer PRN dosage (includetravel time)

Requisition drugs to patientfloor; refills

Credit or dispositionunused medications

Requisition drugs to patient

floor; new orders

Prepare medication cards

Prepare I.V. admixtures

Dispose of syringes

34

PART 11 To the best of your knowledge, do the pharmacists provide thesupport indicated below to your ward/service, and how importantis that function to you? (Check yes, if service is providedand no if the service is not provided.) Circle one number oneach line. even if the service is not provided.

VERY VERYYES/NO UNIMPORTANT NEUTRAL IMPORTANT

Conduct follow-posraino1 2 3 4 5 6 7

patients to determine efficacyof drug therapy

Conduct follow-up observation todetermine possible adverse 1 2 3 4 5 6 7reactions to drug therapy

3. Providing information ondrug dosage 1 2 3 4 5 6 7

4.Participation on emergency team 1 2 3 4 5 6 1 7

'.Part icip:r. ion in the establishmentOf a druig Formnulary for your 1 2 3 4 5 6 7hospital

6. Providing information about adrug that is new or unfamiliar 1 2 3 4 5 6 7

7.Compounding L.V. additives 1 2 3 4 5 6 7

S.Answering questions asked bynurse 1 2 3 4 5 6 7

Maintaining drug therapyinformation on patients 1 2 3 4 5 6 7

Ili. Participation in introduction -

of RN's to pharmacy services at 1 2 3 4 5 6 7your hospital

35

PART IIT Please read each item below, then using the 7-point scale

provided, indicate your SATISFACTION/DISSATISFACTION.

How satisfied or dissatisfied are you with...(irLie one number on each line)

Extremely Neutral Extremely

Dissatisfied Satisfied

1. The pharmacy service as

a whole? 1 2 3 4 5 6 7

2. The drug information providedby the pharmacy service in 1 2 3 4 5 6

response to your request?

2. The information that is placedon inpatient medication labels? 1 2 3 4 5 6 7

4. The availability of the

pharmacist? 1 2 3 4 5 6 7

5. The hours of operation of thepharmacy service? 1 2 3 4 5 6 7

b. The accessibility of the pharmacy

service (i.e., is the location of 1 2 3 4 5 6 7

the pharmacy convenient to you)?

7. The transportation of medication

to the floor? 1 2 3 4 5 6 7

8. The availability of emergency

drugs? 1 2 3 4 5 6 7

9. The contents of emergencymedication carts and kits? 1 2 3 4 5 6 7

10. The unit dose drug distribution

system? 1 2 3 4 5 6 7

I]. The way the pharmacy receives

medication orders (i.e., the way 1 2 3 4 5 6 7

the physicians' orders are

forwarded to the pharmacy)?

12. The pharmacist's monitorinig of

each patient's drug orders and 1 2 3 4 5 6 7

alerting you to potential

allergies, interactions, over-

doses, etc.?

36

-- • m . .... n ,,, -r--,r

Extrmely Neutral ExtremelyDissatisfied Satisfied

13. The way in which an order isfilled, (i.e., failure to fill 1 2 3 4 5 6 7an order or to fill an orderimproperly)?

14. The staffing of the pharmacydepartment? 1 2 3 4 5 6 7

15. The supply and resupply ofthe medication cart (unit dose 1 2 3 4 5 6 7cart)?

16. The ntumber of missing doses? 1 2 3 4 5 6 7

17. Drug discharge consultation bythe pharmacist to orient the 1 2 3 4 5 6 7patient to proper methods andeffects of taking their medica-tion after discharge?

18. The education of patients andf amilies in medication corn- 1 2 3 4 5 6 7liance?

19. Drug therapy monitoring ofselected patients (i.e., regular 1 2 3 4 5 6 7drug profile review, regularchart review, patient contact,etc.) by the pharmacist?

20. Effective commnunication amongnurses, pharmacists, and 1 2 3 4 5 6 7physicians?

21. The amount of medication waste? 1 2 3 4 5 6 7

22. The amount of time it takes anorder to arrive at the pharmacy? 1 2 3 4 5 6 7

23. The amount of time it takes toprocess an order (i.e., fill a 1 2 3 4 5 6 7prescription) within thepharmacy?

37

Extremely Neutral ExtremelyDissatisfied Satisfied

24. The amount of time it takesto administer a drug order to 1 2 3 4 5 6 7the patient after being pro-cessed (i.e., filled) by thepharmacy?

25. The accuracy of the patientmedication profiles? 1 2 3 4 5 6 7

26. Information on the pharmacypatient profile? 1 2 3 4 5 6 7

PART IV Please read each item below, then using the 7-point scale providedindicate how much you AGM or DISAGRIl with the statement.(Circle one number on each line)

Disagree Neutral Agree

1. Pharmacist should practice inpatient care areas 1 2 3 4 5 6 7

2. Pharmacist should monitor eachpatient drug therapy regimen 1 2 3 4 5 6 7by maintaining a patientmedication profile

3. Pharmacist should attend andparticipate in patient care 1 2 3 4 5 6 7rounds

4. Pharmacist abould serve on thehospitals emergency team 1 2 3 4 5 6 7

5. Pharmacist shoul4 performpatient interviews on 1 2 3 4 5 6 7selected patients

6. Pharmacist should providedrug therapy conferences 1 2 3 4 5 6 7for the medical and nursingstaff

7. Pharmacist siduld serve the druinformation needA of the medical 1 2 3 4 5 6 7and nursing staffs

38


8. Pharmacist should check thephysicians drug order prior 1 2 3 4 5 6 7to administration of drugt,. patient

9. The Army should institutedecentralized or satellite 1 2 3 4 5 6 7pharmacy service in itshospitals

10. The Army should implement orexpand clinical pharmacy 1 2 3 4 5 6 7practice in its hospitals

11. The following wards/services should besupported by decentralized/clinicalpharmacy service

11.1 Medical 1 2 3 4 5 6 7

11.2 Medical ICU 1 2 3 4 5 6 711.3 Cardiology 1 2 3 4 5 6 711.4 Neurology 1 2 3 4 5 6 7

11.5 Oncology 1 2 3 4 5 6 7

11.6 Pulmonary Disease 1 2 3 4 5 6 7

11.7 Obstetrics 1 2 3 4 5 6 7

11.8 Gynecology 1 2 3 4 5 6 7

11.9 Pedictrics 1 2 3 4 5 6 7

1.10 Psychiatry 1 2 3 4 5 6 7Nuclear Medicine 1 2 3 4 5 6 7

11.12 Surgery 1 2 3 4 5 6 711.13 Surgical ICU 1 2 3 4 5 6 7

11.14 Urology 1 2 3 4 5 6 711.15 Neurosurgery 1 2 3 4 5 6 711.16 Orthopedics 1 2 3 4 5 6 11

11.17 Other (Specify) 1 2 3 4 5 6 7

39

(STAPLE HERE AFTER FOLDING)

(FOLD ON THIS LINE SECOND)---------------------------------------------------------------------------------

DEPARTMENT OF THE ARMY

H[ALTt! CARE STUDIES I)IVISI()NACADV." T 8 IIFALTH SCIENCES, US AWNORT SAM HOUSTON, TEXAS 78234

HSA-CHCPOSTAGE AND PEES PAID

OFFICIAL BUSINESS DOD 314PENALTY FOR PRIVATE USE. SOO

HEALTH CARE STUDIFS IIVISIONACADEMY OF HEAIIlI SCIINCES, US ARMYFORT SAM HOUSTON, TEXAS 78234

ATTN: CPT Rauch

(FOLD ON THIS LINE FIRST)

40

I

DEPARTMENT OF THE ARMYACADEMY OF HEALTH SCIENCES. UNITED STATES ARMY

FORT SAM HOUSTON. TEXAS 78234

S: 16 July 1979

HSPA- C 25 June 1979


1. In response to a request from the Commander, Health Services Command,the Health Care Studies Division is undertaking a study of the feasibilityand potential utility of a decentralized inpatient pharmacy service.

2. Survey instruments have been developed to obtain data for analysis.Separate questionnaires have been designed for physicians, pharmacistsand nurses. Your name has been randomly selected to constitute the testpopulation. Therefore, your cooperation and assistance is solicited.

3. In support of this pilot study, you are requested to complete theattached questionnaire. When you have completed the questionnaire, foldand staple in accordance with the instructions provided on the last pageand place it in the mail. It is requested that you niail your question-naire not later than 16 July 1979. You may be assured that your responsesand comments shall remain anonymous.

I Inc E.~ HERT ZMD. (as J /COLJ MC

(p~ty Chief of StaffProfessional Activities

AHlS Form 35,5-2 (OT)i July 1919 41

PHARMACY SERVICE SATISFACTION Q=TETWIWWE -FOR FITSICIAMS

In an effort to provide the best health care possible w are asking

you to take a few minutes to reepoa4 to the tpllowift questions anditems. The questionnaire is ** 6; 7kb aM not to Identify

yourself. In this respect, w ask itt you state your honestopinion on all questions ad items. h inuef stion provided willbe held in the strictest confidence.

PART I

1. Age: 2. Sex: Male Female

3. Military Civilian

4. Rank/Grade

5. Duty title MOS

6. Specialty

7. In what year did you pass your boards



10. Are you assigned/employed at a MHDCEH_ _ EDDAC

11. On what clinic, ward or service do you spend the majority of

your time delivering health care

12. How long have you been assigned/employed with your presentMEDCEN/HEDDAC

13. How long have you been assigned/employed with your presentclinic/ward/service

14. Is your ward/service supported by a unit dose distribution system?

Yes No

15. Is your ward/service supported by a decentralized or satellitepharmacy?

Yes No

42

15.1 If yes, are other wards or services supported by the same

decentralized or satellite pharmacy?

Yes No

15.2 If yes, please list the other wards/services?

16. Have you been assigned/employed at other hospitals which provide

decentralized or satellite pharmacy services

Yes No

17 Chi the average, what percent of your working time is spent:

(a) Providing medical care and/or diagnostic servire-?

(b) Performing essentially administrative tasks?

re) Providing professional supervision to other health care

personnel or performing teaching functions?

43

I

PART II To the best of your knowledge, do the pharmacists provide thesupport indicated below to your wrd/srvice, and how imortantis that function to you? Check yen, If ervice is providedand no if it is not provided. Circle one number an each lineeven if the service is not provided.

MUy VERY________________ YES/AD UNM UT NURA MOTN

1. Conduct follow-up observation ofpatients to determine efficacy 1 2 3 4 5 6 7of drug therapy

2. Conduct follow-up observation todetermine possible adverse 1 2 3 4 5 6reactions to drug therapy

3. Providing Information ondrug dosage 1 2 3 4 5 6 7

!4. Participation on emergency team 1 2 3 4 5 6 7

5. Participation in the establish-ment of adrug Formulary for 1 2 3 4 5 6your hospital

6. Providing information about a

drug that is new or unfamiliar 1 2 3 4 5 6

7. Compounding INV. additives 1 2 3 4 5 6 7

8. Answering questions asked byphysicians 1 2 3 4 5 6

9. Maintaining drug therapyinformation on patients 1 2 3 4 5 6

10. Participation in introductionof RN's to pharmacy services 1 2 3 4 5 6at your hospital

_______ ________________

44

"AR' i I Please read each item below, then using the 7-point scaleprovided, indicate your SATISFACTION/DISSATISFACTION.

How sitisfied or dissatisfied are you with...LCtr. Icone number on each line)

fttremely Neutral ExtremelyDissatisfied Satisfied

. Thu pharmacy service asi whole? 1 2 3 4 5 6 7

2. llw drug information providedUv the pharmacy service in 1 2 3 4 5 6i,,sponse to your request?

3. The information that is placedn inpatient medication labels? 1 2 3 4 5 6 7

- he availability of the pharma-cist? 2 3 4 5 6 7

5. The hours of operation of thepharmacy service? 1 2 3 4 5 6 7

6. The accessibility of the pharmacyservice (i.e., is the location 1 2 3 4 5 6 7o' the pharmacy convenient to you)?

7. The transportation of medicationsto the floor? 1 2 3 4 5 6 7

8. The availability of emergencydrugs? 1 2 3 4 5 6 7


10. The unit dose drug distributionsystem? 1 2 3 4 5 6 7

11. The way the pharmacy receivesmedication orders, (i.e., the 1 2 3 4 5 6 7way your orders (prescriptions)are forwarded to the pharmacy)?

45

Extr me ly Neutral ExtremelyDiesattsf ied Satisfied

12. The pharmacist's monitoring ofeach patient's drug orders and 1 2 3 4 5 6 7alerting you to potentialallergies, interactions, over-doses, etc.?

13. The way in which ani order isfilled (i.e., failure to fill 1 2 3 4 5 6 7an order or to fill an orderimproperly)?

14. The staffing of the pharmacydepartment? 1 2 3 4 5 6 7

15. Drug discharge consultations bythe pharmacist to orient the 1 2 3 4 5 6 7patient to proper method. andeffects of taking their medica-tion after discharge?

16. The education of patients andfamilies in medication com- 1 2 3 4 5 6 7p1lance?

17. Drug therapy monitoring ofselected patients (i.e., 1 2 3 4 5 6 7regular drug profile review,regular chart review, patientcontact, etc.) by thepharmacist?

18. Effective commnunication amongnurses, pharmacists and 1 2 3 4 5 6 7physicians?


20. The amount of time it takesfor an order to arrive 1 2 3 4 5 6 7at the pharmacy?

21. The amount of time it takes toprocess an order (i.e., fill 1 2 3 4 5 6 7a prescription) within thepharmacy?


22. The amount of time it takes toadminister a drug order to the 1 2 3 4 5 6 7patient after being proeossed(i.e., filled) by the pharmacy?

23. The accuracy of patient medica-tion profiles? 1 2 3 4 5 6 7

24. Information on the pharmacypatient profile. 1 2 3 4 5 6 7

PART IV Please read each item below, thee uoing the 7-point scale provided,indicate how much you AGRE or DISACREE with the statement.(Circle one number on each line)


1. Pharmacist should practice inpatient care areas 1 2 3 4 5 6 7

2. Pharmacist should monitor eachpatients drug therapy regimen 1 2 3 4 5 6

by maintaining a patientmedication profile


Pharmacist should serve on thehospital emergency team 1 2 3 4 5 6

5. Pharmacist should performpatient interviews on selected 1 2 3 4 5 6 7patients

. Pharmacist should provide drug

therapy conferences for the 1 2 3 4 5 6 7medical and nursing staff

7. Pharmacist should serve thedrug information needs of the 1 2 3 4 5 6medical and nursing staff

47

* - i -


8. Pharmacist should check thephysicians drug order prior 1 2 3 4 5 6 7to administration of drugto patient

9. The Army should institutedecentralized or satellite 1 2 3 4 5 6 7pharmacy service in itshospitals

10. The Army should implement orexpand clinical pharmacy 1 2 3 4 5 6 7practice in its hospitals

11. The following wards/services shouldbe supported by decentralized/clinical pharmacy service

11.1 Medical 1 2 3 4 5 6 7

11.2 Medical ICU 1 2 3 4 5 6 7

11.3 Cardiology 1 2 3 4 5 6 7

11.4 Neurology 1 2 3 4 5 6 7

11.5 Oncology 1 2 3 4 5 6 7


11.7 Obstetrics 1 2 3 4 5 6 7

11.8 Gynecology 1 2 3 4 5 6 7

11.9 Pediatrics 1 2 3 4 5 6 7

11.10 Psychiatry 1 2 3 4 5 6 7

11.11 Nuclear Medicine 1 2 3 4 5 6 7

11.12 Surgery 1 2 3 4 5 6 7

11.13 Surgical ICU 1 2 3 4 5 6 7

11.14 Urology 1 2 3 4 5 6 7

11.15 Neurosurgery 1 2 3 4 5 6 7

11.16 Oethopedics 1 2 3 4 5 6 7

11.17 Other (Specify) 1 2 3 4 5 6 7

48


(FOLD ON THIS LINE SECOND)


HEALTH CARE STUDIES DIVISION.CDADI.: OF, HEALTH SCIENCES, US ARM•"ORT SAM HOUSTON, TEXAS 78234

HSA-CHCPOSTAGE AND FEES PAID

OFFICIAL BUSINESS DOD 314PENALTY FOR PRIVATE USF, 300

HEALTH CARE STUDIES DIVISIONACADEMY OF HEALTH SCIENCES, US ARMYFORT SAI HOUSTON, TEXAS 78234

ATTN: CPT Rauch

------------------------------------------------------------------------------------(FOLD ON THIS LINE FIRST)

49

DEPARTMENT OF THE ARMYACADEMY OF HEALTH SCIENCES. UNITED STATES ARMY

FORT SAM HOUSTON. TEXAS 782340S: 16 July 1979HSPA-C 25 June 1979


1. In response to a request from the Commander, Health Services Command,the Health Care Studies Division is undertaking a study of the feasibilityandI potential utility of a decentralized inpatient pharmacy service.

2. Survey instruments have been developed to obtain data for analysis.Separate questionnaires have been designed for physicians, pharmacistsand nurses. Your name has been randomly selected to constitute the testpopulation. Therefore, your cooperation and assistance is solicited.

3. In support of this pilot study, you are requested to complete theattached questionnaire. When you have completed the questionnaire, foldand staple in accordance with the instructions provided on the last pageand place it in the mail. It is requested that you mail your question-naire not later than 16 July 1979. You may be assured that your responsesand comments shall remain anonymous.

I Inci E. HERTZ , .D. e/COLJ MC(puty Chief of StaffProfessional Activities

\I fS F( rIl m 15 5- '? (0r'1I'/ 1979 50

PiIQAtFIACY SERVICE SATISFACTION QUESTIONNAIRE FOR PHARMACISTS

In an effort to provide the best health care possible we are askingyou to take a few minutes to respond to the following questions anditems. The questionnaire is anonymous; you are not to identifyyourself. In this respect, we ask that you state your honestopinion on all questions and items. The information will be heldin the stric: 2st confidence.

PART I

1. Age:_ 2. Sex: Male Female

3. Military_ Civilian

4. Duty title

5. Licenses, certificates, or registration you hold (specify)

6. Indicate below the degree or degrees you received and the

year you received it (them)

Check as many as apply Year

Ph.G or Ph.C

Bachelor of Arts

Bachelor of Science

Master of Science

Ph.D or D. Sc.

Other (specify)

7. In what year did you pass your boards?



10. Are you assigned/employed at a MEDCEN MEDDAC

11. How long have you been assigned/employed with your presentMJkDCEN/NEDDAC

12. How long have you been practicing hospital pharmacy?

51

13. What are your professional affiliations?

14. Do you practice in a unit dose distribution system?

Yes No (Circle your answer)

15. Do you provide inpatient support from a decentralized orsatellite pharmacy?


15.1 If yes, please indicate the services supported by your

decentralized or satellite pharmacy.

16. Have you been assigned/employed at other hospitals which provided

decentralized or satellite pharmacy service?


17. What percentage of your duty time is spent in support of:

Inpatients %__ Outpatients Z Other 2

18. Please indicate your clinical pharmacy experience:

Length of time

(a) Academic: Yes No _______

(b) OJT: Yes No _______

(c) Clin~cal Practice: Yes No _______

PART II Please indicate if you, as a pharmacist, perform the followingtypes of support and how important you feel that support is tothe overall mission in health care. (Check yes, if service isprovided and no if the service is not provided.)

VERY VERYUSN UNIWMOTAiNT NEUTRAL IMPORTANT

1. Conduct follow-up observation ofpatients to determine efficacy 1 2 3 4 5 6 7of drug therapy X

2. Conduct follow-up observation todetermine possible adverse 1 2 3 4 5 6 7reactions to drug therapy

3. Providing information ondrug dosage 1 2 3 4 5 6 7

4. Participation on drug team 1 2 3 4 5 6 7

5. Participation in the establishmentof a drug Formulary for your 1 2 3 4 5 6 7hospital

6. Providing information about adrug that is new or unfamiiliar 1 2 3 4 5 6 7

7. Compounding I.V. additives 1 2 3 4 5 6 7

8. Answering questions asked bynurSes 1 2 3 4 5 6 7

9. Answering questions asked byphysicians 1 2 3 4 5 6 7

10. Maintaining drug therapyinformation on patients 1 2 3 4 5 6 7

11. Participation in introduction ofRNI's to pharmacy services 1 2 3 4 5 6 7at your hospital

53

PART III Please read each item below, then using the 7-point scaleprovided, indicate your SATISFACTION/DISSATISFACTION.

}Iow satisfied or dissatisfied are you with...(Circle one number on each line)


1. The role provided by thepharmacy service in your 1 2 3 4 5 6 7MEDCEN/MEDDAC towardpatient care?

2. The amount of drug informationthat you are currently providing 1 2 3 4 5 6 7in response to physician andnurse needs?

3. Your availability to provideprofessional services to other 1 2 3 4 5 6 7members of the health care team?

4. The hours of operation of thepharmacy? 1 2 3 4 5 6 7

5. The accessibility of the pharmacyservice (i.e., do you feel the 1 2 3 4 5 6 7location of the pharmacy isconvenient for other membersof the health care team)?

6. The transportation of medicationto the floor? 1 2 4 5 6 7

7. The availability of emergencydrugs for use by the health 1 2 3 4 5 6 7care team?


9. The unit dose drug distribution

system? 1 2 3 4 5 6 7

10. The way the pharmacy receivesorders, (i.e., the way physicians 1 2 3 4 5 6 7orders are forwarded to thepharmacy)?


11. The pharmacist's monitoring ofeach patients' drug orders and 1 2 3 4 5 6 7alerting other health careproviders (nurses, physicians,etc.) to potential allergies,interactions, overdoses, etc.?

12. The staffing of the pharmacydepartment (i.e., the number 1 2 3 4 5 6 7of pharmacists and assistants)?

13. The supply and resupply of themedication cart (unit dose 1 2 3 4 5 6 7cart)?

14. The number of missing doses? 1 2 3 4 5 6 7

15. Drug discharge consultations bythe pharmaci:.t to orient the 1 2 3 4 5 6 7patient to proper methods andeffects of taking theirmedication after discharge?

Vt. The education of patients andfamilies in medication com- 1 2 3 4 5 6 7pliance?

17. Drug therapy monitoring ofselected patients (i.e., regular 1 2 3 4 5 6 7drug profile review, regularchart review, patient contact,etc.) by the pharmacist?

1;. Effective communication amongnurses, pharmacists, and 1 2 3 4 5 6 7physicians?


20. The amount of time it takes anorder to arrive at the pharmacy? 1 2 3 4 5 6 7

21. The amount of time it takes toprocess an order (i.e., fill a 1 2 3 4 5 6 7prescription) within thepharmacy?

55

AIV-


Th~amount of time it takesto administer a drug order 1 2 3 4 5 6 7to the patient after beingprocessed (i.e., filled) bythe pharmacy?

23. Accuracy of patient medicationprofiles? 1 2 3 4 5 6 7

24. Information on the pharmacy patientprofile? 1 2 3 4 5 6 7

25. Your- pay? 1 2 3 4 5 7 7

26. Your opportunity for advancement? 1 2 3 4 5 6 7

27. Use of your education effectively? 1 2 3 4 5 6 7

28. Working conditions? 1 2 3 4 5 6 7

29. Challenging work? 1 2 3 4 5 6 7

30. Forms used for doctor's orders,therapeutic plan, etc? 1 2 3 4 5 6 7

PART IV Please read each item below, then using the 7-point scale provided,indicate how much you AGREE or DISAGREE with the statement.(Circle one number on each line)


1. Pharmacist should practice in

patient care areas i1 2 3 4 5 6 7

2. Pharmacist should monitor eachpatients drug therapy regimen 1 2 3 4 5 6 7by maintaining a patientmedication profile


4. Pharmacist should serve on thehospitals emergency team 1 2 3 4 5 6 7

5. Pharmacist should performpatient interviews on 1 2 3 4 5 6 7seclected patients


6. Pharmacist should providedrug therapy conferences 1 2 3 4 5 6 7for the medical and nursingstaff

7. Pharmacist should serve thedrug information needs of the 1 2 3 4 5 6 7medical and nursing staff

8. Pharmacist should check thephysicians drug orders prior 1 2 3 4 5 6 7to administration of drug topatient

9. The Ar.-iy should institutedecentralized or satellite 1 2 3 4 5 6 7pharmacy service in itshospitals

1io. The Army should implement orexpand clinical pharmacy practice 1 2 3 4 5 6 7in its hospitals

11. Routinely drugs should beadministered by pharmacy 1 2 3 4 5 6 7personnel

12. Patient care will improve whendecentralized/clinical pharmacy 1 2 3 4 5 6 7service is provided

13. There is a need to expand orimplment decentralized/clinical 1 2 3 4 5 6 7pharmacy service at my facility

14. The following wards/services should besupported by decentralized/clinicalpharmacy service

14.1 Medical 1 2 3 4 5 6 7

14.2 Medical ICU 1 2 3 4 5 6 7

14.3 Cardiology 1 2 3 4 5 6 7

14.4 Neurology 1 2 3 4 5 6 7

14.5 Oncology 1 2 3 4 5 6


57


14.7 Obstetrics 1 2 3 4 5 6 7

14.8 Gynecology 1 2 3 4 5 6 7

14.9 Pediatrics 1 2 3 4 5 6 7

14.10 Psychiatry 1 2 3 4 5 6 7

14.11 Nuclear Medicine 1 2 3 4 5 6 7

14.12 Surgery 1 2 3 4 5 6 7

14.13 Surgical ICU 1 2 3 4 5 6 7

14.14 Urology 1 2 3 4 5 6 7

14.15 Neurosurgery 1 2 3 4 5 6 7

14.16 Orthopedics 1 2 3 4 5 6 7

14.17 Other (Specify) 1 2 3 4 5 6 7

PART V There are many functions which a pharmacist can perform to assistother members of the hospital's professional staff. As apharmacist there are some which you may consider of primaryimportance, others which are of only secondary importance and

still others which you feel are really outside the purview ofyour professional responsibility. Would you please circle one

number after each of the following to show how you feel about thefunction.

Primary Secondary Outs:i(1e

Importance Importance My Pur iew

Pirticipation in obtaining drug history uponj,Jmission of a new patient 2 3

z Con,!uct follow-up observation of patients todetermine efficacy of drug therapy 2 3

,nduct follow-up observation of patient toiJtermliw possible adverse reactions to

therapy 2 3

. de consultation with patients to answer

etionls about their drug therapy 1 2 3

t-. eovidiug information on drug dosage 1 2 3

-.IProviding information about compatability or

o11compatability of intended drug therapy 1 2 3

7. Researching drug therapy problems 1 2 3

8. Providing new inforw:ltion about drug therapy 1 2 3

jParticipation or omergency teams 1 2 3

-.,Participation in introduction of interns and

residents to pharmacy services at your hospital 1 2 3

1.f arLicipation in introduction of new RN's to

pharmacy at your hospital 1 2 3

?, Participation in the establishment of a drugFormulary for your hospital 1 2 3

Participation in professional societies 1 2 3

4. OL-gani;:ation of and/or participation in a plan

for follow-up of effectiveness of drug therapy;fter patient has been discharges 1 2

5. Your functions in the drug distribution system 1 2

59

-.--'0-.aS-~-L

Primary Secondary Outside

Importance Importance My Purview

16. Your role as a pharmacist in regard to activities

other than those related to the drug distribution

sy5 tr 1 2 3

'7. Training of pharmacy assistants 1 2 3

[8. Supervision of pharmacy assistants 1 2 3

.9. Interpretation of all physician drug orders 1 2 3

'0. Compounding I.V. additives 1 2 3

ZI. Suggesting drug therapy changes to physicians 1 2 3

?2. Providing information relevant to selected

patients drug therapy 1 2 3

!3. Participation in patient rounds 1 2 3

'4. Presenting drug therapy conferences 2 3

'5. Providing special intensive drug therapy

monitoring of selected patients, on request 1 2 4

,6. Answering questions asked by physicians 1 2 3

'7. Answering questions asked by nurses 1 2 3

'8. Maintaining drug therapy infomnation on

patients 2 3

:9. Asking questions of the drug information

service (DIS) concerning selected patients

drug therapy 2 3

PAR'T VI Based upon the best information available to you, or your bestestimate, how much time per day do you spend in each of thefollowing activities? If none, indicate 0.

Time in minutes

1. Monitoring patient medical records

2. Participating in shift report

3. Answering physician questions

4. Reading professional literature

5. Attending staff meetings _

6. Answering nurses and ward clerk questions

7. Participating in patient rounds

8. Questioning physician orders

9. Working on special projects

10. Interviewing patients

11. Participating on emergency team

12. Processing drug information serviceinquiries

13. Doing p.tient drug therapy research

14. Interpreting orders, checking transcriptionand dose

15. Performing technician duties

13. Checking doses in drawers

17. Preparing I.V. admixture,

18. Transcribing orders

19. Supervising pharmacy technician

20. Preparing E.P. doses

21. Prforming otl,er miscellaneous duties

61


(FOLD ON THIS LINE SECOND)


ft. Xl 1I C.,XR[' STUDIES I)| rS )N,A(A[JI' 'i' IFAITIt SC,:1N(,,S, US ARI h

-'T SAM IlOUSTON, TEXAS 78234HSA-CHC

POSTAGE AND rEES PAID

OFFICIAL BUSINESS DOD 314PENALTY FOR PRIVATE USE, 3O

HEALTH CARE STUDIES DIVISIONACADEMIY OF ltEAI'll S(:I,:NCES, ITS ARMYFORT SAM HOUSTON. rEXAS 78234

ATTN: CPT Rauch

(FOLD ON THIS LINE FIRST)

62

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