Pharmacists’ clinical scope of practice

By Trupti Kulkarni and Anjana Sengar

Hospital pharmacists are uniquely positioned to improve medication safety and efficacy. In order to have the most impact, pharmacists should work to the fullest capacity within their scope of practice. Unlike community pharmacy practice, the professional practice scope of hospital pharmacists is not solely determined by the Pharmacy Act. Rather, scope must be approved by each individual hospital’s Medical Advisory Committee. This means that different Ontario hospital organizations have variances in pharmacist scope of practice based on organization-specific policies, protocols and/or medical directives.

Our team worked together to create a policy for pharmacists’ clinical scope of practice at Trillium Health Partners (THP) in Mississauga, Ontario with an aim to enhance efficacy, safety, timeliness, and cost-effectiveness of patient care. The Pharmacists’ Clinical Scope of Practice Policy allows pharmacists the ability to independently adapt or modify prescriptions if it is in the patient’s best interest, and if the pharmacist has the knowledge, skills and judgement to do so (excluding narcotics, controlled drugs, or targeted substances). Pharmacists can reorder home medications and hold or discontinue medications, if deemed appropriate. Pharmacists are also able to independently order laboratory tests if required to optimize medication therapy management.

Prior to the development and implementation of our Pharmacists’ Clinical Scope of Practice Policy, we knew that we needed a focused strategy to gather feedback from all relevant stakeholders, and to ensure a smooth and sustainable implementation process. We conducted a survey within the pharmacy department to gather opinions on the perceived benefits, drawbacks, facilitators, and barriers of this practice change. In our survey results, we saw that pharmacists expressed readiness for the practice change, and they provided insights into potential barriers to implementation. A review of existing clinical scope policies, protocols, and medical directives from other hospital organizations further informed the development of a policy draft with a practice scope and processes unique to the needs of THP.

In developing the policy, we sought feedback from physicians, nurses, and pharmacists, which we then used to revise our drafts. For example, we removed the ordering of diagnostic imaging from the draft, to prevent potential liability risks of incidental clinical findings associated with diagnostic imaging results. Input from our colleagues also guided the decision to rename the policy from “Expanded Scope” to “Clinical Scope,” to reflect the idea that the interventions mentioned in the policy already lie within the scope of essential services that pharmacists have the knowledge and skills to provide.  The policy was presented to the THP Pharmacy and Therapeutics Committee (P&T), Clinical Policies and Procedures Committee, and Quality and Patient Safety Committee, with final approval granted by the Medical Advisory Committee.

Education and communication were central to implementing the policy. We held pharmacist education sessions to outline the purpose, scope, restrictions, and practical applications of the policy. Pharmacists raised awareness of the policy through mandatory communication at clinical huddles and meetings attended by nursing, allied health, and physician staff. An official communication notice was also sent to all staff to inform them of the policy.

Post-implementation, processes were put in place to ensure appropriate use of the policy. We wanted to ensure that any questions or concerns regarding the practice change were promptly addressed. In team huddles, we encouraged individuals to share their experiences with the policy, and we created an FAQ document available to all hospital staff. Furthermore, the policy is reviewed with all new pharmacist hires during orientation.

After the rollout of the policy, the pharmacy department assessed the impact and appropriateness of pharmacy scope of practice interventions. We collected and reviewed pharmacist orders during first 30 days of the policy’s implementation, to determine what kinds of interventions pharmacists were making. We found that the majority of interventions included adaptations, medication discontinuation, and prescribing.  Our assessment found that pharmacists adhered to the policy and their interventions contributed to increased patient safety, optimized therapy, and improved efficacy of drug therapy.

This carefully planned policy implementation resulted in a successful change in scope of clinical practice for pharmacists at THP. This innovation empowers pharmacists to use their knowledge and skills to the fullest to optimize patient care.