Close Up on Complaints: A Shared Responsibility for Ethical and Effective Pharmacy Services
This “Close Up on Complaints” will follow a slightly different format than previous issues of Pharmacy Connection. In this issue, the case under review will be used to highlight a more systematic issue concerning the dual responsibilities of the individual professional (pharmacists and pharmacy technicians) and the corporation (including designated managers, owners and directors) when providing pharmacy services. The following discussion will examine the role and responsibility of each when providing pharmacy services to ensure optimal health outcomes for the patient.
Summary of the Incident
This incident occurred when a pharmacist at Pharmacy A conducted a MedsCheck review for a regular patient who had multiple medical conditions and received weekly compliance aids from the pharmacy. When the pharmacist submitted the MedsCheck claim, it was rejected by the Ontario Drug Benefit (ODB) program for the reason that a MedsCheck had already been billed for this patient at another pharmacy, Pharmacy X, a few months before.
The patient did not currently attend Pharmacy X and had visited the pharmacy to purchase a blood glucose meter. The pharmacist at Pharmacy X conducted the MedsCheck without first reviewing the patient record and therefore was not aware that the patient had not filled a prescription at the pharmacy for over a year. The pharmacist did not request the patient’s prescription history from his current pharmacy, Pharmacy A.
In addition, the patient did not recall participating in a MedsCheck from Pharmacy X. The patient remembered discussing his medical conditions but was unaware he was being provided a specific pharmacy service as opposed to the counselling he normally received from the pharmacist.
Why Did this Happen
The pharmacist working at Pharmacy X did not conduct the patient’s MedsCheck in accordance with the Standards of Practice and Code of Ethics. The pharmacist did not consult the patient record or request the patient’s medication history from Pharmacy A, and therefore did not have the appropriate information to complete a thorough review of the patient’s medication.
Pharmacy X used computer software to identify potential patients that would qualify for a MedsCheck. Owners, directors, designated managers, and pharmacists and pharmacy technicians are reminded that while software and other methods can be used to encourage the provision of pharmacy services and identify potential opportunities to provide services, the service should only be delivered where the pharmacist reviews the specific patient circumstances and determines that the service is in the patient’s best interest. Only those services that would benefit the patient and optimize care should be provided. In this case, it was apparent that there had been a communication breakdown between those responsible for setting organizational expectations around pharmacy services and the front line pharmacists and pharmacy technicians who deliver them.
Complaint Outcome
The College’s Inquiries, Complaints & Reports Committee (ICRC) oversees investigations of each complaint the College receives. The Committee considers a pharmacist’s or pharmacy technician’s conduct, competence and capacity by assessing the facts of each case, reviewing submissions from both the complainant and the pharmacist or pharmacy technician, and evaluating the available records and documents related to the case.
Your commitment to your professional role requires that you make decisions based on the needs and best interest of the patient and not your personal or business interests.
In considering this case, the Committee noted that while the pharmacist felt he was facing corporate pressure to complete pharmacy services, pharmacists and pharmacy technicians are accountable for their practice as a member of a regulated health profession and must ensure they are acting ethically and within the parameters of the Standards of Practice.
The Committee found that the pharmacist had not completed some of the fundamental steps involved in a MedsCheck, such as gathering a best possible medication history. The Committee issued advice and recommendations to the pharmacist to assist him in being more thoughtful in practice and ensuring he act in an ethical manner at all times, regardless of the corporate pressure he might be facing or his own personal or business interests.
The Committee also acknowledged that corporations, designated managers or directors on behalf of a corporation have a responsibility to ensure that pharmacy services are provided in a professional manner. The best interest of the patient must be the primary consideration and provision of any service must allow for the pharmacist or pharmacy technician to apply his or her professional judgement. Designated managers have the same practice obligations as registered pharmacists, in addition to being accountable for the operation of the pharmacy to ensure it supports pharmacists and pharmacy technicians in their cognitive and patient care functions.
Learning for Pharmacists, Pharmacy Technicians, Designated Managers, Directors and Corporations
Reflecting on this complaint provides pharmacists and pharmacy technicians and their employers with a number of learning opportunities to help improve the delivery of any pharmacy service. As noted above, while this example specifically refers to MedsChecks, the purpose of this Close Up on Complaints is to illustrate the importance of equal partnership between pharmacists and pharmacy technicians, and designated managers, directors and owners to ensure that all pharmacy services are provided appropriately with the goal of optimizing the health of patients. Healthcare providers must never forget that the most important characteristic of a healthcare professional is that they are committed, first and foremost, to the direct benefit of their patients and only secondarily to making a profit.
Learning for Pharmacists and Pharmacy Technicians
The Standards of Practice and Code of Ethics clearly outline the responsibility of every individual pharmacist and pharmacy technician to maintain the patient’s best interest as the core of all activities and to demonstrate personal and professional integrity when providing patient care. Regardless of a practitioner’s position or practice environment, when a pharmacist or pharmacy technician performs a specific role, they must perform it to the level specified in the Standards of Practice and meet the standards associated with that role.
As a pharmacist or pharmacy technician, your commitment to your professional role requires that you make decisions based on the needs and best interest of the patient and not your personal or business interests. Patients trust that healthcare professionals will use their specialized knowledge, skills and judgement to make decisions that enhance their health and well-being based on each patient’s
individual needs and circumstances.
This may not always be as simple as it sounds, and pharmacists and pharmacy technicians, will, at times, be required to evaluate whether providing a pharmacy service is professionally and ethically appropriate for the patient. Pharmacists and pharmacy technicians are accountable for any decision or action taken while providing patient care, including whether or not to provide a specific pharmacy service.
It is a practical reality that time constraints and limited resources will impact the provision of pharmacy services. This does not mean that the most appropriate option is to not provide any pharmacy services.
Pharmacists must prioritize the provision of pharmacy services and use their professional judgment to determine which patients will most benefit from receiving a service.
To determine where to most appropriately allocate these services, pharmacists must consider the patient’s medical history and other relevant factors, and where necessary seek information and ask questions of the patient to ascertain if the current or proposed medication provides the most appropriate therapy. By using professional judgment to determine the appropriateness of a pharmacy service, pharmacists and pharmacy technicians can ensure that services provided are of good quality and in accordance with the Standards of Practice.
Lastly, pharmacists and pharmacy technicians must be clear and transparent regarding any pharmacy services provided. Prior to providing a service, the pharmacist or pharmacy technician must inform the patient about what service they are providing so that the patient can make an informed decision about whether to receive the service from that pharmacy.
Learnings for Designated Managers, Directors and Corporations
The Standards of Practice outline the responsibilities of a pharmacist when managing a pharmacy and the Standards of Accreditation (under the Drug and Pharmacies Regulation Act) outline the responsibilities of the designated manager, owner and directors when operating a pharmacy.
The Standards of Practice require designated managers to develop and implement policies and procedures that support continuous quality improvement and to ensure that staffing and workflow enable pharmacists and pharmacy technicians to fulfil standards of practice and optimize patient care.
There is an overarching obligation on designated managers, directors and corporations to support the provision of quality services.
The Standards of Accreditation require the provision of the necessary equipment, systems and staffing needed to allow members practicing in the pharmacy to meet the standards of practice of the profession.
The standards, taken together, create an overarching obligation on designated managers, directors and corporations to support the provision of quality services. This expectation applies to any service provided by pharmacists and pharmacy technicians.
Recognizing Shared Responsibilities to Provide Patient Centered Care
The College holds pharmacists, pharmacy technicians, designated managers, and directors (on behalf
of corporations) accountable where professional obligations, expectations and responsibilities are not met – and equally enforces the clearly outlined responsibilities accorded to each role.
If a complaint comes to the College, a pharmacist or pharmacy technician cannot say that they had to do something (e.g. perform a medication review) that was not in the patient’s best interest. A designated manager or director cannot say that they didn’t know the appropriate environment, staffing or resources were not in place to support pharmacists and pharmacy technicians in providing quality patient care. It is the professional responsibility of pharmacists, pharmacy technicians, designated managers and directors of corporations to ensure that each workplace environment supports the delivery of ethical and quality pharmacy services.
Pharmacists and pharmacy technicians need to ensure that they inform an appropriate person with oversight of pharmacy operations (e.g. pharmacy manager, designated manager, district manager) if they do not have the support required to practice to the Standards of Practice or if they reasonably believe human resources, policies, procedures, working conditions or the actions, professional performance or health of others may compromise patient care or public safety.
Designated managers and directors are required to ensure that each pharmacy – and corporation – maintains appropriate human resources to support pharmacists and pharmacy technicians in meeting the Standards of Practice.
Frequent and clear communication between pharmacists and pharmacy technicians, designated managers, owners and directors is essential to ensure that the pharmacy environment is sufficiently supported to provide services that are appropriate and of good quality. While it is acknowledged that business needs will be a consideration in the design and implementation of pharmacy services, the primary consideration must always be the patient’s best interest.