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A Required Course in the Development, Implementation, and Evaluation of

Clinical Pharmacy Services

Article in American Journal of Pharmaceutical Education · November 2008

DOI: 10.5688/aj7205109 · Source: PubMed

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 American Journal of Pharmaceutical Education 2008; 72 (5) Article 109.

INSTRUCTIONAL DESIGN AND ASSESSMENT

A Required Course in the Development, Implementation, and Evaluation
of Clinical Pharmacy Services
Monica L. Skomo, PharmD, Khalid M. Kamal, PhD, and Hildegarde J. Berdine, PharmD
Duquesne University Mylan School of Pharmacy
Submitted November 14, 2008; accepted February 29, 2008; published October 15, 2008.

Objective. To develop, implement, and assess a required pharmacy practice course to prepare phar-
macy students to develop, implement, and evaluate clinical pharmacy services using a business plan
model.
Design. Course content centered around the process of business planning and pharmacoeconomic
evaluations. Selected business planning topics included literature evaluation, mission statement de-
velopment, market evaluation, policy and procedure development, and marketing strategy. Selected
pharmacoeconomic topics included cost-minimization analysis, cost-benefit analysis, cost-effectiveness
analysis, cost-utility analysis, and health-related quality of life (HRQoL). Assessment methods included
objective examinations, student participation, performance on a group project, and peer evaluation.
Assessment. One hundred fifty-three students were enrolled in the course. The mean scores on the
objective examinations (100 points per examination) ranged from 82 to 85 points, with 25%-35% of
students in the class scoring over 90, and 40%-50% of students scoring from 80 to 89. The mean scores
on the group project (200 points) and classroom participation (50 points) were 183.5 and 46.1, re-
spectively. The mean score on the peer evaluation was 30.8, with scores ranging from 27.5 to 31.7.
Conclusion. The course provided pharmacy students with the framework necessary to develop and
implement evidence-based disease management programs and to assure efficient, cost-effective utili-
zation of pertinent resources in the provision of patient care.
Keywords: clinical pharmacy services, pharmacoeconomics, business plan

INTRODUCTION 12.1 specifically describes the outcome expectations for

The vision for future practice of pharmacy has the students completing this required course. Clinical fac-
prompted a mandate for pharmacy educational revision, ulty members devoted time to business planning with
supported both by a large number of professional organ- application to different practice settings where students
izations and by the revised accreditation standards.1-4 The learn to provide patient-centered care ‘‘through the ability
goal of 3 faculty members—2 clinical and 1 pharmacy to manage a successful patient-centered practice includ-
administration—at Duquesne University Mylan School ing establishing, marketing, and being compensated for
of Pharmacy was to develop a course that taught doctor medication therapy management and patient care services
of pharmacy (PharmD) students how to design, imple- rendered.’’5 Guideline 12.1 also requires that students are
ment, and evaluate clinical pharmacy services in an in- able to show the ability to deliver pharmaceutical care by
teractive learning environment. In addition, the faculty learning about ‘‘population specific, evidence-based clin-
wanted to integrate the new educational competencies ical service programs, developed upon analysis of epide-
described in the accreditation standards and guidelines miologic and pharmacoeconomic data.’’ These topics are
into the required pharmacy practice course. The course delivered in the classroom and students exhibit their mas-
described in this article incorporates the ACPE Accredi- tery of the subject matter by writing a group business plan
tation Standards and Guidelines for the Professional Pro- for a clinical service program. The completion of this
gram in Pharmacy under Standard No. 12: Professional business plan for a clinical service with pharmacoeco-
Competencies and Outcome Expectations.5 Guideline nomic analysis meets the systems management outcome
demonstrating the students’ ability to ‘‘ensure efficient,
Corresponding Author: Monica L. Skomo, PharmD, 308 cost-effective use of human, physical, medical, informa-
Bayer Learning Center, 600 Forbes Ave, Pittsburgh, PA, tional, and technological resources.’’
15282. Tel: 412-396-1809. Fax: 412-396-5130. E-mail: The rationale for the course was a perceived need by
[email protected] our faculty that future pharmacists working in a variety of
1
 American Journal of Pharmaceutical Education 2008; 72 (5) Article 109.

practice settings will require education on how to take 4. Create a business plan for a hypothetical phar-
ideas for new program development and translate them macy service.
into the real world of practice and financial accountabil- 5. Discuss the application of pharmacoeconomic
ity. The rationale was validated by pharmacists who evaluations in clinical, hospital, and community
attended continuing education programs on immuniza- practice, managed care organizations, and other
tion theory and practice. They consistently expressed an practice settings.
interest for more course time devoted to developing and 6. Synthesize a plan to economically evaluate a
implementing an immunization practice into their own hypothetical pharmacy service.
working environment.6 Students on advanced pharmacy The course consisted of three 50-minute class periods
practice experiences or in internships also reported that per week. Selected lecture topics are shown in Table 1 in
they were being asked to design and assist in implement- the order of presentation. The first 5 weeks of the course
ing new pharmacy service programs. encompassed describing the parts of a business plan and
The required course is part of a sequence of pharmacy how to develop a business plan for pharmacy services.
practice courses. It is a 3-credit hour course entitled Phar- The backbone of this first portion of the course was a thor-
macy Practice V: Clinical Pharmacy Services and Phar- ough exploration of the business plan model developed by
macoeconomics that was initially offered during fall G. Schumock and its application to the development of
semester 2006 to the third-year class of 153 students. This different clinical services for various patient popula-
course is part of a series of courses beginning in the first tions.7 The business planning portion of the course cov-
semester of the first year. Pharmacy Practice I covers the ered the process for literature evaluation, development of
concepts and philosophy associated with patient-centered mission statements, evaluating the market and competi-
care and pharmaceutical care. Pharmacy Practice II is tors, operations and processes, policies and procedures,
a course dedicated to learning communication and inter- SWOT (strengths, weaknesses, opportunities, threats)
viewing skills and application of those skills to a real analysis, marketing strategy, and action plans and time-
world self-selected patient. Pharmacy Practice III is the lines. Additional topics discussed during this time period
self-care course. Pharmacy Practice IV teaches physical included clinical and quality requirements, standards of
assessment skills, screening techniques, interpretation of care, pharmacy compensation for clinical pharmacy serv-
laboratory values, and principles of health promotion and ices, and collaborative agreements. The second 5 weeks
disease prevention. This article will describe the design, of the course focused on describing and discussing vari-
methods of evaluation, and results of implementing Phar- ous clinical pharmacy services that have been imple-
macy Practice V: Clinical Pharmacy Services and Phar- mented in a variety of practice settings. Selected
macoeconomics so that other faculty members who are services described included an anticoagulation monitor-
interested in curricular development in view of the new ing program, a hospital decentralized pharmacy service,
accreditation standards and expected new educational a critical care pharmacy service, an immunization serv-
outcomes may benefit from our experiences. ice, a dyslipidemia management clinic, a diabetes self-
management clinic, a long-term care infection control
DESIGN service, and a medication therapy management service.
The primary purpose of the course was to provide The last 5 weeks of the course concentrated on pharma-
students with the knowledge and skills necessary to (1) coeconomics and outcomes research. Selected topics in-
develop a business plan (2) implement clinical pharmacy cluded cost-minimization analysis, cost-benefit analysis,
services in different practice settings and (3) evaluate the cost-effectiveness analysis, cost-utility analysis, and
economic, clinical, and humanistic outcomes (ECHO) of health-related quality of life (HRQoL). Lecture material,
the service. Selected course objectives included: discussion, and examples in the pharmacoeconomic
1. Describe the role of the mission statement in portion were directed toward clinical pharmacy services.
program planning, how to identify and evaluate The foundational principles of pharmacoeconomic
a market and competitors of a clinical pharmacy analysis were tied together with the business plan
service, and how to develop a marketing strat- model in an effort to provide full integration of topic
egy for a clinical pharmacy service. areas and to demonstrate real world viability of a proposed
2. Identify pertinent clinical and quality require- service.
ments/standards of care for various ambulatory The 3 textbooks required for the course were
and health systems clinical pharmacy services. How to Develop a Business Plan for Clinical Pharmacy
3. Describe the parts of and how to write an effec- Services: A Guide for Managers and Clinicians,7Hand-
tive business plan for a clinical pharmacy service. book of Institutional Pharmacy Practice, 4th edition,8
2
 American Journal of Pharmaceutical Education 2008; 72 (5) Article 109.

Table 1. Lecture Topics in Pharmacy Practice V: Clinical management system. The syllabus and all course hand-
Pharmacy Services and Pharmacoceconomics outs were posted on Blackboard for the students to access
Business Planning and print if desired. In addition, students had access to
1. Exploring the business concept TurningPoint (Turning Technologies, LLC, Youngstown,
2. Literature evaluation OH) slides used in class, group project information, fac-
3. Mission and mission statements ulty information, and assigned articles. All assigned
4. Evaluating the market and competitors articles were placed on electronic reserve with the Uni-
5. Clinical and quality requirements/Standards of care versity library to provide easy student access and comply
6. Proposed operations and processes
with copyright regulations. Blackboard also gave students
7. Policies and procedures
the ability to see their test and project scores and commu-
8. Risks and opportunities
9. Compensation nicate with classmates and instructors. Course faculty
10. Marketing strategy members frequently communicated with students via
11. Collaborative agreements e-mail and by posting announcements for the class on the
12. Credentialing and scope of practice course Blackboard site. A major part of student assess-
13. Action plan/Timeline ment in the course was a group project. The Group Pages
14. Writing the business plan feature of Blackboard was utilized to facilitate communi-
Clinical Pharmacy Services cation among students in their groups. Group Pages func-
1. Health-systems services tions that were used by students included the group
a. Antibiotic streamlining discussion board, collaboration sessions (virtual class-
b. Medication reconciliation room and chat), file exchange, and e-mail.
c. Medication adherence clinic
The instructors of the course felt strongly that a sig-
2. Ambulatory care services
nificant part of the course should involve students
a. CLIA and laboratory service requirements
b. Pharmacy-based immunization service employing higher-level thinking skills including evalua-
c. Lipid clinic tion, synthesis, creativity, and other elements of critical
d. Diabetes clinic thinking. Hence, in addition to 3 objective examinations,
e. Medication Therapy Management (MTM) service the students were required to complete a group project,
3. Long-term care and individual classroom participation was factored into
a. Consultant practice the students’ grades for the course.
b. Infection control service Each objective examination consisted of 50 questions
4. Indigent care services/Charitable pharmacies worth 2 points each (total of 100 points). Objective ex-
5. Hospice and palliative care amination scores comprised 55% of the course grade.
Pharmacoeconomics and Outcomes Research Each examination covered approximately a third of
1. Data sources for economic analysis
the course material. All examination questions were in
2. Partial economic evaluations: cost of illness and cost
multiple-choice format.
analysis
3. Cost-minimization analysis For the group project, students were required to de-
4. Cost-benefit analysis velop a business plan and economic evaluation for a hy-
5. Cost-effectiveness analysis pothetical clinical pharmacy service. The purpose of the
6. Cost-utility analysis project was to give students the opportunity to apply and
7. Health-related quality of life (HRQoL) integrate the ideas and concepts they learned in class, as
8. Use of decision modeling in conducting well as to employ several higher-level thinking skills.
pharmacoeconomic studies Students were assigned to a group ranging in size from
9. Use of guidelines to evaluate and interpret 8 to 9 students. Each group randomly selected their pro-
pharmacoeconomic literature ject pharmacy service from a group of 6 different scenar-
10. Applications of pharmacoeconomics and ios, which included an immunization service, a lipid
pharmacoeconomic study evaluation
clinic, a diabetes clinic, an anticoagulation clinic, a med-
ication reconciliation service, and a nursing home service.
and Principles of Pharmacoeconomics, 3rd edition.9 In Each scenario included background information about the
addition to the textbooks, several current readings from pharmacy or institution where the service would be of-
the primary literature were assigned to reinforce key con- fered. Pertinent information included type of pharmacy,
cepts and provide real world examples. location, number of full-time pharmacist and support staff
The course was organized and managed using the members, hours of operation, prescription volume, and
Blackboard (Blackboard Inc, Washington, DC) course pharmacy layout and space availability. Each group also
3
 American Journal of Pharmaceutical Education 2008; 72 (5) Article 109.

had to designate a team coordinator. Responsibilities of Table 2. Group Project Rubric Categories, Subcategories, and
the team coordinator included: Point Distribution
d Coordinating the efforts of the individual mem- Number of
bers of the group Category Possible Points
d Corresponding with group members Project Writing and Presentation 20 total
d Corresponding with course faculty members re- d Spelling, grammar, punctuation,
garding the project sentence structure 5
d Arranging meetings for the group d Level of writing and organization 10
d Setting individual, team, and project goals d Literature review 5
d Maintaining the project timeline Executive Summary 15 total
d Submitting the final draft of the project
Background and Description 15 total
d Background information 5
Students were told that their business plan and eco-
d Description of services and mission 5
nomic evaluation should include the following sections:
d Rational and purpose of program 5
title page, table of contents, executive summary, back- Marketing Analysis and Strategy 20 total
ground and description, marketing analysis and strategy, d Evaluation of market 10
operational structure and process, milestones/schedule/ d Marketing strategy 10
action plan, economic evaluation of the service, conclu- Operational Structure and Process 20 total
sion, supportive documents (job descriptions and flyer or d Service delivery 10
brochure). d Clinical, regulatory, and quality

Students received a rubric created by course faculty requirements 10

members for the project. The rubric was detailed and Milestones, Schedule, and Action Plan 10 total
served as a valuable tool for students to be successful in Pharmacoeconomic Assessments 45 total
d Problem statement, background,
this assignment. A copy of the rubric is available from the
authors. The group project was worth 200 points and and perspective 15
d Methodology 30
comprised 36% of the course grade. Information regard-
Conclusion 5 total
ing the content areas of the group project rubric and point Supportive Documents 20 total
distribution is located in Table 2. d Job descriptions 10
Each student was expected to make substantial indi- d Flyer or brochure 10
vidual contributions to the project. Therefore, the instruc- Collaboration Score 30 total
tors decided to base 15% of the project grade on the Total 200 points
collaboration and work skills of each individual student.
Students were evaluated by their group peers in 8 different
work skill areas on a Likert scale of 1 to 4 on which teaching assistants would have access to these evalua-
1 5 poor, 2 5 average, 3 5 good, and 4 5 excellent. A tions. Also, each group member evaluated all members
ninth area addressed the leadership and communication of the group except him/herself. If a student did not sub-
skills of the team coordinator. Students performed these mit peer evaluations for each member of the group,
evaluations using the Group Project Collaborative Work that student would have 10 points deducted from the
Skills Peer Evaluation, which was adapted by course fac- individual project score.
ulty from a collaborative work skills rubric found on the Student participation in class was worth 50 points and
Web10 and consisted of the following categories: contri- comprised 9% of the course grade. At each lecture,
bution of ideas and participation, workload, problem
solving, focus, time management, attitude, teamwork,
pride, team coordinator skills (applies only to the team Table 3. Collaboration Points Earned Based on Average Peer
Evaluation Score
coordinator).
A copy of the Work Skills Peer Evaluation is avail- Average Peer Number of Collaboration
able from the authors. Scores from all peer evaluations Evaluation Score Points Earned
were averaged. The average score determined how many .29.0 30
points the student earned as an individual in the area of 25.0 – 28.9 25
collaboration. Table 3 illustrates how average peer eval- 21.0 – 24.9 20
uation scores were translated into collaboration points. 17.0 – 20.9 15
13.0 – 16.9 10
Students were informed that all peer evaluations
,13.0 5
would be kept confidential and only course faculty and
4
 American Journal of Pharmaceutical Education 2008; 72 (5) Article 109.

instructors presented questions in a multiple-choice or Table 5. Distribution of Grades

true/false format to the class using the TurningPoint au- Grade Number of Students Percent of Class
dience response system. Students were able to respond to A 55 35.9
the questions using a radio-frequency keypad. Individual A- 26 17
student answers were tracked and participation was eval- B1 29 19
uated based on the number of lectures in which students B 34 22.2
actively participated. Aside from the first class and B- 7 4.6
examinations, there were 40 lecture/classroom meeting C1 2 1.3
times. Students earned points based on the number of
classes in which they participated. Students who partici-
pated in 38 or more classes earned 50 participation points; ment, and evaluate pharmacy clinical services. Center for
30 to 37 classes, 40 points; 25 to 29 classes, 30 points; 20 the Advancement of Pharmaceutical Education (CAPE)
to 24 classes, 20 points, and 19 classes or less, 10 points. Outcomes were successfully integrated into the new
course as evidenced by the students’ ability to develop
ASSESSMENT and implement clinical services through systematic appli-
One hundred fifty-three students were enrolled in the cation of business planning principles as reflected through
course. Evidence of student learning was captured their group projects. In line with the revised educational
through 3 objective examinations, a group project, and outcomes put forth by the American Association of Col-
classroom participation. The results of these evaluations leges of Pharmacy (AACP), the course assisted students
are presented in Table 4. The mean scores on the objective in making a connection between what they learned and the
examinations (100 points per examination) ranged be- potential applications in their practice.
tween 82 and 85 points, with 25%-35% of students in The course assessed students’ performance through
the class scoring over 90 points, and 40%-50% of students objective examinations and a group project. The group
scoring from 80 to 89 points. The mean scores on the project comprised one third of the course grade and re-
group project (200 points) and classroom participation quired students to develop a business plan and economic
(50 points) were 183.5 and 46.1, respectively. As de- evaluation of a clinical pharmacy service. Based on the
scribed earlier, each student evaluated group peers in content and quality of the group projects submitted by the
8 different work skills, with scores ranging from 4 to students, the course faculty members were confident
32. The mean score on group project peer evaluation about the students’ ability to develop, implement, and
was 30.8, with scores ranging from 27.5 to 31.7. The evaluate new pharmacy programs. Also, advocates of col-
scores on the 3 objective examinations were analyzed to laborative learning assert that group activity not only
see how students were performing on the tests. Table 5 increases student interest in the course materials but also
gives the distribution of class grades; 52.9% of students encourages critical thinking.11-13 The presence of a peer
scored an A minus or better. support system helps students assimilate external knowl-
edge, take responsibility for their own learning, and de-
DISCUSSION velop critical thinking skills.13,14 The course also used
Consistent with the educational revision mandated by a group peer-evaluation format that facilitated student
a large number of professional pharmacy organizations learning and helped them evaluate team dynamics and
including the ACPE, this new pharmacy practice course team performance characteristics. Given the changing
offered students an opportunity to actively design, imple- nature of pharmacy practice and that pharmacists are in-
creasingly working in teams, the instructors decided that
this unique collaborative work-skill assessment tool
Table 4. Student Assessment Results (n 5 153) would provide students with feedback regarding their
Min Max Mean (SD) Median effectiveness of working in a group.
Exam 1 66 100 85.49 (6.78) 86 The course has been offered once and all students
Exam 2 58 98 83.71 (7.50) 84 enrolled in the course received a passing grade. Results
Exam 3 54 98 82.80 (8.54) 84 of student performance and assessment and student eval-
Group project 152 198 183.49 (9.28) 185 uations suggest that the course was valuable for students
Group 27.48 31.74 30.75 (1.02) 31 learning the development, implementation, and evalua-
peer-evaluation tion of clinical pharmacy services using a systematic
Class 30 50 46.08 (5.53) 50
business plan. The course offered a variety of activities
participation
to help develop and improve critical thinking and writing
5
 American Journal of Pharmaceutical Education 2008; 72 (5) Article 109.

skills. Even though the students achieved passing scores velop and implement evidence-based disease manage-
on their examinations and assignments, there were concerns ment programs and to assure efficient, cost-effective
expressed regarding course workload and relevancy of the utilization of pertinent resources in the provision of pa-
material with regards to the daily activities of apharmacist. tient care. The course will continue to emphasize to our
The course was a positive experience for the faculty students the growing importance of offering and evaluat-
members. Even though the course required intensive ing innovative clinical pharmacy services.
preparation, from designing the syllabus and group proj-
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