5 Tips: Implementing change in your pharmacy

The evolution of pharmacists’ roles in the ever-changing healthcare landscape (for example, throughout the COVID-19 pandemic) and the substantial evidence for the benefits of the care that pharmacists provide, mean it is more important than ever that pharmacists be well equipped to implement change.(1,2) Healthcare providers tend not to easily accept change, and pharmacists are no exception to that rule. As a result, implementation science is being used as a tool to guide practice change and to better understand the parts of effective change implementation.(1,2) Implementation science provides a number of models, theories and frameworks. One of the frameworks, Promoting Action on Research Implementation in Health Services (PARiHS), states that successful change implementation is centred around adequately addressing three main components: evidence, context and facilitation.(3) Let’s say you are confident about the positive impact of a new change (e.g., a new service or practice model) on your patients or on the system and organization. Your enthusiasm can be supported by research, your clinical experience, patient experience or local data (the evidence). This is a great starting point! The prerequisite of success is there and you can move to the heart of the implementation process: the context, which is the environment where you want to implement the change. Context is a complex construct involving the culture, leadership, monitoring and feedback system of an organization or system. The context determines whether the change will be supported or not.(3) What can be done with the context if some aspects are not conducive to practice change? This is where the third key ingredient comes into play: facilitation. Facilitation is a process of providing the means to implement the change. Solving problems and providing support are the key parts of facilitation. Facilitation can be internal (to the organization), external (with outside experts), or blended (a combination of both); highly effective facilitation involves both internal and external agents playing certain roles.(4) Pharmacists can use the following five tips from external and internal facilitation to help successfully implement a change. 1) Ensure everyone is on board Make sure that pharmacy team members understand the importance of the issue, and can see evidence that the change you are trying to implement in your organization will address this issue. Does your team see the need to implement this new service and why? Are they interested in addressing the practice issue? What is their incentive to change? Are key stakeholders engaged? Is there a pharmacy champion who will establish the focus on change during the implementation? Ensuring that all these questions are addressed will help with clarity and motivation among all team members to proceed with implementation.(5) 2) Make all players active contributors to the change implementation Lack of engagement and ownership will get in the way of effective implementation.(6) Even if team members do see the need for change, this change needs to be “their” project from the very beginning. Enabling others, rather than focusing on “doing for others,” promotes a high level of facilitation.(7) Also, forming teams of facilitators (if the change is being implemented at multiple sites) can be very effective for mutual support, generating decisions, sharing experiences and increasing the collective ability to implement the change.(8) 3) Make sure that the context in the organization is supportive of the change Context broadly alludes to the settings/organization where the change is being implemented and how it supports the change. It encompasses culture (e.g., My organization values innovation), leadership (e.g., I am clear on my role within the team) and evaluation (e.g., We have multiple sources of evaluation that are routinely collected). When experienced facilitators were asked about factors of successful and unsuccessful change implementation, most of the factors were associated with context. Diagnostic tools can be used to identify problem areas and resolve future problems.(5,9) For example, the PARiHS set of diagnostic questions about evidence and context can identify areas that need more attention and effort (see example statements above).(7) These tools can also help to identify the facilitation strategy.(5,10,11) 4) Ensure the availability of technical and practical support Conducting a barriers assessment and developing a resolution plan can be valuable strategies.(5) For example, when facilitating the implementation of medication management services, some barriers (e.g., cumbersome documentation and the lack of data integration) can be resolved by using shorter documentation and streamlining how notes are integrated into the dispensary software.(2,6) A common challenge to successful implementation of a change is the lack of resources. Flexibility and thinking “outside the box” are critical to finding solutions when not enough resources are available. Possible solutions could be academic or clinical partnerships to enhance the implementation process, involving non-pharmacy staff, and optimizing appointments and time spent with patients to create extra time for change implementation.(2,6) 5) Be flexible. Specify, create and match facilitation strategies to the situation, people and evidence Flexibility is crucial for successful implementation as expectations might not match the reality. For example, facilitation strategies used at the beginning of the implementation process might not work over time and have to be adapted.(5) Getting team members on board might take longer than planned due to certain barriers that were not known during the planning phase (e.g., possession of certain skills or quality of communication channels). In this fast-changing world, the expectations for how new services are implemented should be realistic (e.g., significantly scaled-down or put on hold during the vaccination season). Summary The goal of the facilitation process is to make change implementation easier by providing support and problem solving. Those involved in the facilitation process should be seen as a resource, rather than an authority, with directive and persuading messages. Ideally, the whole team should be involved in facilitating change. Flexibility, the ability to use multiple change strategies and tenacity are the most important characteristics for successful change implementation.(5) Tatiana Makhinova (tatiana.makhinova@ualberta.ca) is an Assistant Professor, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, University of Alberta in Edmonton, AB. She has developed and evaluated a few community pharmacy initiatives in respiratory care, which sparked her interest in implementation science References: 1. Tsuyuki R, Bond C. The evolution of pharmacy practice research – Part I: Time to implement the evidence. Can Pharm J 2019;152(2):71-2. 2. Houle S, Charrois T, Faruquee C, et al. A randomized controlled study of practice facilitation to improve the provision of medication management services in Alberta community pharmacies. Res Social Adm Pharm 2017;13(2):339-48. 3. Rycroft-Malone J. The PARiHS framework - a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual 2004;19:297-304. 4. Kirchner J, Ritchie M, Dollar K, et al. Implementation facilitation training manual: using external and internal facilitation to improve care in the Veterans health administration. In: US Department of Veterans Affairs HSRaD, Mental Health Quality Enhancement Research Initiative; 2013. 5. Dogherty E, Harrison M, Graham I, et al. Turning knowledge into action at the point-of-care: the collective experience of nurses facilitating the implementation of evidence-based practice. Worldviews Evid Based Nurs 2013;10(3):129-39. 6. Siu A, Krass I, Mitchell B, et al. Implementation of diabetes screening in community pharmacy – factors influencing successful implementation. Res Social Adm Pharm 2021;17: 1606-13. doi: 10.1016/j.sapharm.2020.12.013. 7. Rycroft-Malone J. Promoting action on research implementation in health services (PARIHS). In: Rycroft-Malone J, Bucknall T. Models and frameworks for implementing evidence-based practice: linking evidence to action. Chichester, West Sussex: Wiley-Blackwell, 2010; p. 110-35. 8. McCullough M, Gillespie C, Petrakis B, et al. Forming and activating an internal facilitation group for successful implementation: a qualitative study. Res Social Adm Pharm 2017;13(5):1014-27. 9. Stetler C, Damschroder L, Helfrich C, et al. A guide for applying a revised version of the PARIHS framework for implementation. Implement Sci 2011;6(99):1-10. 10. Kitson A, Rycroft-Malone J, Harvey G, et al. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Science 2008;3(1):1. 11. McCormack B, McCarthy G, Wright J, et al. Development and testing of the Context Assessment Index (CAI). Worldviews Evid Based Nurs 2009;6(1):27-35.

5 Tips: Implementing change in your pharmacy

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