Organizational factors influencing pharmacy practice ...

Research in Social and Administrative Pharmacy j (2011) j–j

Original Research

Organizational factors influencing pharmacy practice change William R. Doucette, Ph.D.a,*, Justin C. Nevins, Pharm.D.b, Caroline Gaither, Ph.D.c, David H. Kreling, Ph.D.d, David A. Mott, Ph.D.d, Craig A. Pedersen, Ph.D.e, Jon C. Schommer, Ph.D.f a

Division of Clinical and Administrative Pharmacy, College of Pharmacy, University of Iowa, S518 PHAR, Iowa City, IA 52242, USA b Division of Health Services Research, Target Corporation, 4575 W 11th Ave, Eugene, OR, 97402, USA c College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109-1065, USA d School of Pharmacy, University of Wisconsin, 777 Highland Ave., Madison, WI 53705, USA e Craig A. Pedersen Consulting, Seattle, WA, USA f College of Pharmacy, University of Minnesota, 5-130 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455, USA

Abstract Background: Some pharmacists have changed the focus of their practice from solely dispensing. Emerging services they have added include medication therapy management and other pharmacy services. Objective: To assess the effect of entrepreneurial orientation, resource adequacy, and pharmacy staffing on pharmacy practice change. Methods: A total of 1847 licensed U.S. pharmacists received 2 mail surveys as part of a larger national pharmacist survey. The core survey collected information about practice setting, prescription volume, and staffing. The supplemental survey assessed how the pharmacy had changed over the past 2 years to enable the delivery of pharmacy services. The amount of change was assessed by 12 items, which were summed to provide an aggregate change index. Five variables from organizational change literature were assessed as influences on practice change: proactiveness, risk taking, autonomy, work ethic, and adequacy of resources. In addition, the associations of pharmacist and technician staffing with practice change were assessed. A multiple linear regression analysis was performed with the aggregate change index as the dependent variable and the 7 potential influences on change as the independent variables. Results: Four hundred usable surveys were analyzed. At least some level of practice change was reported in 60% of pharmacies surveyed. The linear regression analysis of the model was significant (P ! .001) with an R-square value of 0.276. Significant influences on change were 2 dimensions of entrepreneurial orientationdproactiveness and autonomydas well as adequacy of resources and pharmacy technician staffing. Conclusions: Many pharmacies reported that some aspects of their practice have changed, such as collecting patient information and documenting care. Few reported changes in asking patients to pay for pharmacy services. These findings support previous results, which show that the capacity for organizational change can be

* Corresponding author. Tel.: þ1 319 335 8786; fax: þ1 319 353 5646. E-mail address: [email protected] (W.R. Doucette). 1551-7411/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2011.07.002

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Doucette et al. / Research in Social and Administrative Pharmacy j (2011) 1–11

augmented by increasing proactiveness, autonomy among employees, and the availability of adequate and appropriate resources. Ó 2011 Elsevier Inc. All rights reserved. Keywords: Pharmacy practice; Change; Organization; Entrepreneur

Introduction In recent history, pharmacy practice has focused on dispensing prescription medications, although it is evolving to encompass new pharmacy services.1-4 Two forces affecting the evolution of pharmacy practice have been the profession’s support for medication management activities and the shrinking profitability of dispensing. To varying degrees, both of these factors have supported pharmacy practice change to incorporate new pharmacy services into practice. There is a growing recognition that pharmacists are society’s experts on medications. For example, section 30.4 of Centers for Medicare & Medicaid Services Prescription Drug Benefit Manual about medication therapy management (MTM) programs states that “MTMPs should be developed in cooperation with licensed and practicing pharmacists and physicians.”5 Even so, the adoption of MTM into practice is still in its early stages.2 Recently, however, the decreasing reimbursement rate from third-party payers for dispensing fees and the relative increase in the cost of operation have encouraged some pharmacies to seek new sources of revenue. Increasing societal demand for health care also has influenced some pharmacies to expand their practice.6-13 The transition of a pharmacy practice from a focus on dispensing to one that embraces pharmacy service delivery requires the rearrangement of resources. These resources include tangible items such as the financial resources, the physical layout, equipment, and staffing of the pharmacy as well as intangible resources such as the knowledge and skills of the pharmacists to develop, implement, and effectively market services.14,15 Many pharmacies will have to shift their layout and workflow to accommodate patient care, such as MTM services, into their practice site. Although the ability of a pharmacy to change to allow the delivery of pharmacy services has been described conceptually, it has received limited empirical study.7,16-21 However, the process of organizational change has been well documented in business literature, and several facilitators of

change have been identified that could apply to pharmacy practice. These factors include aspects of entrepreneurial orientation (EO) and resource adequacy. Aspects of EO that affect the ability to change include proactiveness, risk taking, autonomy, and work ethic.6,22-29 The availability of adequate and appropriate resources also is a vital antecedent to change.6,30 The purpose of this study was to assess the association between a set of organizational factors and pharmacy practice change. The objective of this study was to assess how EO dimensions, resource adequacy, and pharmacy staffing influence pharmacy practice change.

Factors influencing practice change To be successful over the long term, organizations should continually adapt to their changing markets. This translates into the need for various types of change to meet evolving needs. The business literature suggests that for short-term and long-term success, companies need to pursue incremental innovations, architectural innovations, and discontinuous innovations.31-33 Incremental innovations or changes are defined as small improvements on existing products or operations that increase efficiency. For example, a community pharmacy may frequently alter staffing or inventory in response to current demands. Architectural innovations refer to applying technological or process advantages to fundamentally alter a business practice. This would include increasing dispensing efficiency through the purchase and integration of some form of automation into a community pharmacy. Finally, to support performance over time, businesses should pursue discontinuous innovations, which are defined as radical advances that profoundly alter the basis of competition in an industry. Adding a mix of cognitive services to complement dispensing services in a pharmacy practice is an example of a discontinuous change. Discontinuous innovations or changes serve as the origin of industrial transformation. Although exploratory activities can help organizations broaden their markets and render old business practice


obsolete, it is important that they do not interfere with the performance of the existing business. This contrast forms the notion of an ambidextrous organization, defined as a firm where new exploratory ventures are structurally independent from the traditional units.31-36 Although the structure and processes of the 2 business models are divided, senior management remains tightly integrated across the units. This approach would afford pharmacies the ability to pursue innovative pharmacy services while not interfering with traditional dispensing functions. The EO of an organization profoundly affects an organization’s capacity to change its activities and resources. The concept of EO denotes the processes, practices, and decision-making activities that lead to new venture creation.23,37 Previous research has supported the association of EO on the delivery of pharmacy services. Doucette and Jambulingam6 showed that EO is a useful indicator of whether a pharmacy will develop new pharmacy services.3 They examined innovative pharmacy services, which in that study included specialized compounding, asthma care management, patient compliance monitoring, diabetes care management, and formal evaluation of patients’ health risks. Pharmacies were determined, based on survey responses, to have either high or low EO. A significantly higher proportion of high-EO pharmacies than low-EO pharmacies provided 5 of 7 innovative services. As mentioned earlier, dimensions of EO that directly affect change capability include proactiveness, risk taking, autonomy, and work ethic.6,22-29 Proactiveness refers to processes designed to scan and react to the current environment to anticipate future needs.22 Anticipating future needs enables pharmacies to identify needed resources to create the capacity for practice change. For example, a pharmacy may hire pharmacists with residency training to support future delivery of services that use advanced clinical skills. Risk taking is the degree to which an organization is inclined to engage in these breakthrough initiatives.22 When a pharmacy expands its focus to include the delivery of pharmacy services, it must allocate valuable resources without a guaranteed return on the investment. Pharmacies with a greater proclivity for risk taking will likely be more willing to change their practice. Another possible influence on innovative organizational change is autonomy, which refers to employees being responsible for their work as well as evaluating their own performance.6,38,39 It also denotes the extent to which management is willing

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to consider ideas brought forth by employees. Intrinsically motivated employees are more likely to emerge when leaders empower them by increasing their control over resources. When organizations encourage autonomy, it fosters employee communication and commitment, which in turn enhances innovative behaviors.38 Motivated employees working in a culture of open communication can reduce employee resistance to change, which increases the organization’s change capacity. The final dimension of EO that can affect the ability of an organization to change is work ethic. Work ethic describes attitudes toward and moral belief in hard work.6 The development and implementation of pharmacy services can be challenging, but hardworking highly motivated employees can facilitate practice change. In addition, adequate and appropriate resources are required for successful change to occur.6,7,30,40-42 An organization’s capacity for change is directly related to the presence of sufficient appropriate resources. Resources extend beyond financial and operational support to include time, intelligence, and knowledge. For example, pharmacists might need continuing education to develop the clinical knowledge and skills to deliver MTM services. Pharmacies that are tightly staffed likely have smaller resource reserves to allocate to practice change. In such cases, staffing levels might need to be increased to support delivery of new pharmacy services. Adequate resources help to ensure that employees will not feel overwhelmed or distracted, which likely would result in resistance to further change.30 Furthermore, resource adequacy includes the possession of specific skills, such as service development and marketing, in the practice. Finally, practice change would be difficult without staff members who will keep a pharmacy’s traditional roles functioning well, thereby empowering others to chart a new course. Proactive, motivated, and well-trained pharmacists and pharmacy technicians also are invaluable. These concepts lead to 2 fundamental factors that determine the ability of a pharmacy to change its practice: (1) an EO toward the practice and (2) the availability of sufficient resources that are appropriate for change to occur. The EO dimensions (proactiveness, risk taking, autonomy, and work ethic) often drive a pharmacy’s strategy to bring forth new services. Devoting sufficient resources, including personnel, to exploratory activities can help pharmacies change successfully. This approach encourages breakthrough changes while not diminishing efforts to maintain traditional business practices.

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Methods The source of data for this study was the 2004 National Pharmacy Workforce Survey, which was used to describe the pharmacist workforce: their demographics, their work characteristics, and their work attitudes. This study relied on responses from 2 surveys mailed together to a random sample of 1847 U.S. pharmacists in 2004. The sample frame for the survey was a list of 264,000 licensed pharmacists maintained by KM Lists, Inc. Subjects were potentially contacted 5 times, including 3 follow-up methods (a postcard, second mailing, and telephone call or mailed final reminder). The core survey contained questions about their pharmacy practice situation, including practice setting (eg, independent community pharmacy), daily prescription volume for community pharmacies, and pharmacy staffing. The workplace survey asked about pharmacy services offered, dimensions of EO, adequacy of resources to provide pharmacy services, and how much the pharmacy had changed over the past 2 years. Most questions were taken or adapted from previously published workforce surveys, including those conducted by the coauthors. The amount of change that had occurred in the pharmacy over the past 2 years was assessed by 12 items (Table 1). These items reflected areas common to pharmacy practice that one would expect to need modification to accommodate new areas of pharmacy services.14 Pharmacists rated how much the component listed in each item had changed in their pharmacy using a 3-point scale: none, a little, or a lot. The results were recoded into 2 categories. A response of “none” was categorized as “no change” and was assigned a value of “0.” Responses of “a little” or “a lot” were categorized as “some change” and were assigned a value of “1” for purposes of data analyses. An aggregate practice change index was calculated for each pharmacy by summing the recorded responses to the 12 items. The levels of proactiveness, risk taking, autonomy, and work ethic were each measured by 3 items using a 5-point Likert scale.6 The perceived adequacy of resources was measured by 6 items that included both tangible and intangible resources. Each item was rated using a 5-point scale measure developed previously by Iyer et al (1 ¼ poor, 5 ¼ excellent).43,44 Scores for the EO variables and the adequacy of resources were calculated through summation of the items for each measure. Reliability coefficients were calculated for the multi-item measures.

The data were analyzed using SPSS 18.0 for Windows (IBM, Chicago, IL, USA). Only the responses from actively practicing pharmacists were included in the analysis. Descriptive statistics were calculated for all items. Using a multiple linear regression approach (ordinary least squares), the dependent variable was the aggregate change index and the independent variables included proactiveness, risk taking, autonomy, work ethic, adequacy of resources, pharmacist staffing, and pharmacy technician staffing. To control for staffing levels in the practice setting, pharmacist and pharmacy technician staffing variables were modeled using dummy variables with the comparators of at least 3 pharmacists on duty and at least 3 technicians on duty. The study was approved by the Human Subjects Office at the University of Wisconsin.

Results A total of 611 of the 1847 delivered core and workplace surveys were returned (33.1%). Of the 611 returned surveys, 478 were from actively practicing pharmacists. Four hundred of the returned surveys contained data on aspects of practice change (Table 1). The main reason for an unusable survey was item nonresponse. A total of 347 surveysdor 18.8% of those deliveredd contained complete data on the variables analyzed in the regression (Tables 2 and 3). The amount of change is reported in Table 1. Overall, 60% of pharmacies reported some change (a little þ a lot) across all practice types. Mass merchandisers reported the lowest amount of change, with 50% of them reporting some change in their practices. Across all practice types, the 2 areas that exhibited the largest percentage of change were the skills and knowledge of the pharmacists, as well as the responsibilities and activities of pharmacy technicians at 84% (62% þ 22%) and 82% (47% þ 35%), respectively. The 2 areas in which the lowest amount of change occurred across all practice types were asking patients to pay for pharmacy services and collection of patient laboratory data at 16% (13% þ 3%) and 27% (19% þ 8%), respectively. Slightly more than half of the pharmacists reported that their community pharmacies were dispensing less than 201 prescriptions daily (Table 2). About 38% of the pharmacists reported that for the majority of their workday, a single pharmacist typically was on duty. In contrast, more than half of the respondents reported

Type of practice change

Independent (n ¼ 76)

Chain (n ¼ 136)

Mass merchandiser (n ¼ 22)

Supermarket (n ¼ 35)

Hospital (n ¼ 88)

Other patient care (n ¼ 43)

Total (n ¼ 400)

The information collected about patients The system for documenting patient care The skills and knowledge of our pharmacists Responsibilities and activities of pharmacy technicians Staffing patterns in the pharmacy Layout and workflow of the pharmacy Marketing activities Interactions with physicians Asking patients to pay for pharmacy services Drug information access Financial incentives for pharmacists Collection of patient laboratory data Overall average % change (a little/a lot)

76a 68 87 82 71 70 60 62 24 73 42 12 60

80 76 87 88 69 67 68 58 16 67 49 10 61

73 73 73 77 64 54 45 27 0 54 45 9 50

57 61 78 83 53 61 58 42 17 61 61 9 57

79 84 84 78 71 53 20 78 12 72 33 69 61

77 74 81 79 68 76 69 63 22 73 39 43 64

76 75 84 82 68 64 54 60 16 69 44 27 60

(61/15)b (44/24) (59/28) (52/30) (54/17) (37/33) (49/11) (51/11) (17/7) (53/20) (34/8) (8/4) (43/17)

(53/27) (50/26) (66/21) (46/42) (48/21) (32/35) (54/14) (51/7) (14/2) (54/13) (44/5) (9/1) (43/18)

(64/9) (37/36) (59/14) (41/36) (41/23) (31/23) (36/9) (27/0) (0/0) (49/5) (36/9) (9/0) (36/14)

(48/9) (44/17) (67/11) (58/25) (50/3) (55/6) (52/6) (39/3) (17/0) (44/17) (55/6) (9/0) (49/8)

(46/33) (38/46) (59/25) (48/30) (47/24) (25/28) (18/2) (57/21) (12/0) (43/29) (26/7) (42/27) (38/23)

(49/28) (39/35) (58/23) (43/36) (48/20) (39/37) (48/21) (44/19) (17/5) (59/14) (30/9) (36/7) (43/21)

(52/24) (44/31) (62/22) (47/35) (49/19) (34/30) (43/11) (49/11) (13/3) (51/18) (37/7) (19/8) (42/18)

Note: Data reported by actively practicing pharmacists, who are defined as a licensed pharmacist who is working full time or part time in their primary employment setting. Chain is a combination of small chain and large chain settings. Hospital is a combination of government and nongovernment hospitals. Other Patient Care Practice is defined as settings where pharmacists are providing patient care and is a combination of health maintenance organization-operated pharmacies, clinic pharmacies, mail service, nuclear, nursing home/long-term care, home health, and armed services. Amount of change in the pharmacy was measured on a 3-point scale of none, a little, and a lot. a Percentage of pharmacists reporting their site has experienced some changedwhether a little or a lotdin each item in the past 2 y. b Percentage of pharmacists reporting a little/a lot of change.


Table 1 Percent of pharmacists reporting change (a little/a lot) in their practice sites

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Table 2 Characteristics of pharmacy practice sample Practice characteristic

Mean standard deviation

Reliability coefficienta

EO Proactivenessb Risk takingb Autonomyb Work ethicb

10.29 2.42 8.32 2.31 9.35 2.52 11.22 2.20

0.77 0.83 0.73 0.79

16.49 4.98

0.88

Adequacy of resourcesc Daily prescription volume (n ¼ 301) 0-130 prescriptions per day 131-200 prescriptions per day 201-300 prescriptions per day O300 prescriptions per day d,e

77 80 72 72

(25.6) (26.6) (23.9) (23.9)

NA NA NA NA

Number of pharmacists on dutye 1 2 3

132 (38) 92 (27) 123 (35)

NA NA NA

Number of technicians on dutye %2 At least 3

162 (47) 185 (53)

NA NA

Aggregate change indexf

7.14 2.81

0.76

Note: N ¼ 347 unless otherwise stated. a Cronbach coefficient alpha. b Measure is sum of 3 items that used a 5-point scale: 1, strongly disagree; 2, disagree; 3, neither disagree nor agree; 4, agree; and 5, strongly agree. c Measure is sum of 6 items that used a 5-point scale: 1, poor; 2, fair; 3, good; 4, very good; and 5, excellent. d Data are for community pharmacy settings. e Data are frequency (%). f Measure is sum of 12 items assessing change that has occurred in the past 2 y: the information collected about patients, the system for documenting patient care, the skills and knowledge of the pharmacists, responsibilities and activities of pharmacy technicians, staffing patterns, layout and workflow of the pharmacy, marketing activities, interactions with physicians, asking patients to pay for pharmacy services, drug information access, financial incentives for pharmacists, and collection of patient laboratory data. Responses were coded as 1 for any change and 0 for no change and then summed.

that at least 3 pharmacy technicians typically were on duty. The reliability coefficients for all of the multi-item measures exceeded 0.70. The average change score, 7.14, means that the typical pharmacy reported change in at least 7 of the 12 areas. The multiple linear regression analysis of the model was significant (P ! .001), with an R-square value of 0.276 (Table 3). Proactiveness, autonomy, and adequacy of resources were positive predictors of practice change. Staffing of less than 3 pharmacy technicians was a negative predictor of practice change, compared with 3 or more technicians on duty. Work ethic, risk taking, and pharmacist staffing did not have a significant influence on practice change.

Discussion The most commonly reported changes that occurred in pharmacies over the previous 2 years included (1) the patient information collected, (2) the pharmacy’s documentation system, (3) the skills and knowledge of the pharmacists, and (4) the responsibilities and activities of the pharmacy technicians. The reported changes in the collected patient information and the manner in which that information is documented could be because of the continued growth of insurance coverage,45 as well as the delivery of new pharmacy services.2,4 It is likely that different patient information would be needed to deliver MTM services or immunizations, compared with dispensing services.46


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Table 3 Regression results of influence on pharmacy practice change Standardized b coefficient

Practice characteristic a

T-value

P-value

Proactiveness

0.204

2.875

.004

Risk takinga

0.015

0.275

.784

0.154

2.348

.019

0.048

0.474

.420

a

Autonomy

a

Work ethic

0.274

4.703

!.001

Number of pharmacists on dutyc 1 2

0.065 0.040

0.996 0.747

.320 .456

Number of technicians on dutyd %2

0.127

2.192

.029

b

Adequacy of resources

Note: Because the prescription volume was not measured for respondents in Hospital and Other Practice settings, we did not include it in the regression model. Dependent variable of the regression was the Aggregate Change Index. Model: R-square ¼ 0.276, F-statistic ¼ 16.103, P-value % .001, N ¼ 347. a Measure is sum of 3 items that used a 5-point scale: 1, strongly disagree; 2, disagree; 3, neither disagree nor agree; 4, agree; and 5, strongly agree. b Measure is sum of 6 items that used a 5-point scale: 1, poor; 2, fair; 3, good; 4, very good; and 5, excellent. c Comparator is 3 pharmacists on duty. d Comparator is at least 3 technicians on duty.

As pharmacies expand their service offerings, their information technology should evolve to support those new services.47 The 4 most common changes are representative of incremental and architectural innovations. For example, the implementation of a new computerized patient record system is representative of an architectural innovation. That is, technology was applied to alter the documentation process. Changing the responsibilities and activities of the pharmacy technicians can be viewed as an incremental innovation, which could increase dispensing efficiency and decrease pharmacist time spent on technical duties. With pharmacists’ attention freed up from technical duties and patient records at their fingertips, it is more feasible that new pharmacy services can be launched. Of course, the extent to which such a strategy will be pursued is not known. The occurrence of practice change was significantly associated with 4 variables: 2 dimensions of EO (proactiveness and autonomy), the availability of adequate and appropriate resources, and pharmacy technician staffing. The result for the proactiveness is consistent with an exploratory study of community pharmacy practice change that reported a positive link between practice change and a tendency to consider future success in pharmacy decisions.7 A pharmacy that proactively

addresses market conditions can identify and react to emerging trends and market demands. By staying up-to-date on current practice trends and attending professional meetings, pharmacists can position their practices to take advantage of current market opportunities. For example, a pharmacist who is actively communicating with local physicians may discover that some physicians are having trouble controlling patients with chronic disease states such as hypertension. Once the need for a hypertension management service has been established, the pharmacist could work with the local physicians to implement a disease state management service for patients with hypertension. Being the first to offer such a service may enable the pharmacy to create a competitive advantage in the market and possibly create some brand loyalty among physicians. Pharmacy practice change also can be facilitated by promoting and responding to employee creativity, as shown by the positive association with autonomy. Encouraging open communication of novel ideas rather than allowing superiors or organizational processes to inhibit them can be an impetus for new market entry. Pharmacy employees are in frequent contact with patients, which positions them to identify market opportunities and vital new service ideas. For example, a creative employee could call a pharmacist’s or

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administrator’s attention to the fact that their pharmacy has numerous patients who refill their medications weeks later than expected and might benefit from an adherence service. Finally, the availability of adequate and appropriate resources can support successful practice change.7 Necessary resources include financial and operational support and the skills and knowledge to implement change. For example, pharmacists need to have current clinical knowledge to deliver cognitive services. However, up-to-date clinical evidence alone is not sufficient if other resources are lacking, such as inadequate staffing levels. Other resources, such as a convenient documentation and billing system, service routines, and proper clinical space, would allow pharmacists to perform new practice-changing activities. This study has some limitations that should be considered. One is that the response rate was relatively low. This creates concern about nonresponse bias, if the nonrespondents were different than the respondents. Respondents were compared with nonrespondents through a nonrespondent survey, and nonrespondents were found to be more likely to practice in independent pharmacies. No other difference was identified. Caution should be used in generalizing these results to all pharmacy types. A second limitation is that this survey asked respondents to assess how various aspects of their practice changed over a 2-year period. This could produce recall bias in that respondents may not remember everything that has changed. Difficulty in recall may have contributed to nonresponse for some of the survey items. Future research An exploratory study found that taking action for the future and strengthening pharmacy resources were associated with practice change in community pharmacies.7 This study builds on that one by using concepts from theories of business organization, such as EO and resource adequacy, to investigate pharmacy practice change. The consistent findings support this conceptual approach and suggest future research in this area. For example, a future longitudinal study could track how modifying pharmacy resources and entrepreneurial activities change a panel of new pharmacy services over time. Some work in Australia on creating capacity to deliver cognitive services uses the concept of organizational flexibility, which provides promise for continued research in this area.21

The finding of autonomy as an influence on practice change identifies a challenge for large retail chains with pharmacies, something also noted by Lumpkin et al and Perepelkin and Findlay.24,39 The notion of autonomy is that good ideas brought forth at lower levels of the organizational hierarchy get supported, so they can be fully developed and evaluated. For large organizations, this means that an idea raised by a pharmacist at one outlet might have to go through multiple levels to be considered at the organizational level. Because it is more difficult for ideas to rise to the top of large retail chains, it may be more of a challenge for large pharmacy organizations to keep in touch with their patients through their practitioners. Future researchers could study the mechanisms large retail chains use to foster and support new service ideas within their organization and how effective they are. For example, researchers could track how new pharmacy services are brought into a retail chain over time. Third, future research could focus on developing a complete robust theory of pharmacy practice change beyond the business change concepts this study relied on. The conceptual model for pharmacy practice change used in this study adds to a growing body of knowledge of the subject, although little empirical work has been done. Holland and Nimmo16-20 have developed a model of practice change that focuses on changing individual practitioners and their ability to perform new activities in practice. The Holland-Nimmo model posits that practice change is supported by 3 components: a supportive practice environment, the availability of learning resources for pharmacy staff, and the use of strategies to motivate pharmacy staff to change. One case report on the use of the model to guide practice change in a medical center found limited support for it.44 A conceptual framework for community pharmacy practice change was developed by Roberts et al.48 This framework, based on organizational change theory and social network concepts, suggests that to understand pharmacy practice change, 4 related areas should be investigated: professional roles, experiences with implementation and dissemination, change strategies, and networks. More recently, Roberts et al49 identified 7 facilitators of practice change in Australian pharmacies, including relationship with physicians, remuneration, pharmacy layout, patient expectation, manpower/ staff, communication and teamwork, and external support/assistance. Unlike in this study, EO dimensions and resources (aside from staffing) were not identified as facilitators. A third approach is based


on organizational culture, which reflects a pharmacy being able to provide new services. Two specific approaches include a study of pharmacy service orientation and an organizational culture gap analysis.50,51 Future empirical research is needed to test and further develop these theories of pharmacy practice change, which is consistent with other researchers’ recommendations.39

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Conclusion Pharmacy practice change is complex and affected by entrepreneurial activities and the availability of sufficient pharmacy resources. These results are consistent with previous research that found that practice change occurs when EO is present in a pharmacy, through elements such as administrators being proactive and supportive of new ideas from all levels of the organization. In addition, administrators need to ensure that adequate resources are available to foster and nurture pharmacy practice change. References 1. Hepler CD. The third wave in pharmaceutical education: the clinical movement. Am J Pharm Educ 1987; 51:369–385. 2. Anderson S. The state of the world’s pharmacy: a portrait of the pharmacy profession. J Interprof Care 2002;16(4):391–404. 3. Roberts AS, Hopp T, Sorensen EW, et al. Understanding practice change in community pharmacy: a qualitative research instrument based on organizational theory. Pharm World Sci 2003;25(5):227–234. 4. Barnett MJ, Frank J, Wehring H, et al. Analysis of pharmacist-provided medication therapy management (MTM) services in community pharmacies over 7 years. J Manag Care Pharm 2009;15(1):18–31. 5. Centers for Medicare & Medicaid Services. Section 30.4 Available at: https://www.cms.gov/Prescrip tionDrugCovContra/Downloads/Chapter7.pdf; Accessed 24.05.11. 6. Doucette WR, Jambulingam T. Pharmacy entrepreneurial orientation: antecedents and its effect on the provision of innovative pharmacy services. J Soc Admin Pharm 1999;16(1):26–37. 7. Doucette WR, Koch YD. An exploratory study of community pharmacy practice change. J Am Pharm Assoc (Wash) 2000;40:384–391. 8. Grabenstein JD. Pharmacists as vaccine advocates: roles in community pharmacies, nursing homes, and hospitals. Vaccine 1998;16(18):1705–1710. 9. DeName B, Divine H, Nicholas A, Steinke DT, Johnson CL. Identification of medication-related problems and health care provider acceptance of

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

9

pharmacist recommendations in the DiabetesCARE program. J Am Pharm Assoc 2008;48(6):731–U735. Villa LA, Von Chrismar AM, Oyarzun C, Eujenin P, Fernandez ME, Quezada M. Pharmaceutical care program for dyslipidemic patients at three primary health care centers: impacts and outcomes. Lat Am J Pharm 2009;28(3):415–420. Fera T, Bluml BM, Ellis WM, Schaller CW, Garrett DG. The diabetes ten city challenge: interim clinical and humanistic outcomes of a multisite community pharmacy diabetes care program. J Am Pharm Assoc 2008;48(2):181–190. Kassam R, Farris KB, Burback L, Volume CI, Cox CE, Cave A. Pharmaceutical care research and education project: pharmacists’ interventions. J Am Pharm Assoc (Wash) 2001;41(3):401–410. Cranor CW, Christensen DB. The Asheville project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc 2003;43: 149–159. Rovers JP, Currie JD, Hagel HP, et al. A Practical Guide to Pharmaceutical Care. 2nd ed. Washington, DC: American Pharmaceutical Association; 2003. Desselle SP, Zgarrick DP. Pharmacy Management Essentials for all Practice Settings. New York, NY: McGraw-Hill; 2005. Holland RW, Nimmo CM. Transitions, part 1: beyond pharmaceutical care. Am J Health Syst Pharm 1999;56:1758–1764. Nimmo CM, Holland RW. Transitions in pharmacy practice, part 2: who does what and why. Am J Health Syst Pharm 1999;56:1981–1987. Holland RW, Nimmo CM. Transitions in pharmacy practice, part 3: effecting changedthe three-ring circus. Am J Health Syst Pharm 1999;56:2235–2241. Nimmo CM, Holland RW. Transitions in pharmacy practice, part 4: can a leopard change its spots? Am J Health Syst Pharm 1999;56:2458–2462. Nimmo CM, Holland RW. Transitions in pharmacy practice, part 5: walking the tightrope of change. Am J Health Syst Pharm 2000;57:64–72. Feletto E, Wilsom LK, Roberts AS, Benrimoj SI. Measuring organizational flexibility in community pharmacy: building the capacity to implement cognitive pharmaceutical services. Res Social Adm Pharm 2011;7:27–38. Lumpkin GT, Dess GG. Clarifying the entrepreneurial orientation construct and linking it to performance. Acad Manag Rev 1996;21(1):135–172. Rauch A, Wiklund J, Lumpkin G, Frese M. Entrepreneurial orientation and business performance: an assessment of past research and suggestions for the future. Enterpren Theor Pract 2009;33(3):761–787. Lumpkin GT, Cogliser CC, Schneider DR. Understanding and measuring autonomy: an entrepreneurial orientation perspective. Enterpren Theor Pract 2009;33(1):47–69. Dess GG, Lumpkin GT. The role of entrepreneurial orientation in stimulating effective corporate

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26. 27.

28.

29.

30.

31. 32.

33.

34.

35.

36.

37.

38.

39.

Doucette et al. / Research in Social and Administrative Pharmacy j (2011) 1–11 entrepreneurship. Acad Manag Exec 2005;19(1): 147–156. Miller D. The correlates of entrepreneurship in three types of firms. Manag Sci 1983;29:770–791. Covin JG, Slevin DP. Strategic management of small firms in hostile and benign environments. Strat Manag J 1989;10:75–87. Hart S. An integrative framework for strategymaking processes. Acad Manag Rev 1992;17:327– 351. Hughes M, Morgan RE. Deconstructing the relationship between entrepreneurial orientation and business performance at the embryonic stage of firm growth. Ind Mark Manag 2007;36(5):651–661. Kerber K, Buono AF. Rethinking organizational change: reframing the challenge of change management. Organ Devel J 2005;23(3):23–38. O’Reilly CA, Tushman ML. The ambidextrous organization. Harv Bus Rev 2004;82(4):74–81. Birkinshaw J, Gibson C. Building ambidexterity into an organization. MIT Sloan Manag Rev 2004;45(4): 47–55. Gibson CB, Birkinshaw J. The antecedents, consequences and mediating role of organizational ambidexterity. Acad Manag J 2004;47(2):209–226. Kauppila O-P. Creating ambidexterity by integrating and balancing structurally separate interorganizational partnerships. Strat Organ 2010;8(4):283–312. Raisch S, Birkinshaw J, Probst G, Tushman ML. Organizational ambidexterity: balancing exploitation and exploration for sustained performance. Organ Sci 2009;20(4):685–695. O’Reilly CA, Tushman ML. Ambidexterity as a dynamic capability: resolving the innovator’s dilemma. Research in Organizational Behavior, Vol 28: an Annual Series of Analytical Essays and Critical Reviews 2008;28:185–206. Jambulingam T, Kathuria R, Doucette WR. Entrepreneurial orientation as a basis for classification within a service industry: the case of retail pharmacy industry. J Oper Manag 2005;23(1):23–42. Muthusamy SK, Wheeler JV, Simmons BL. Selfmanaging work teams: enhancing organizational innovativeness. Organ Dev J 2005;23(3):53–66. Perepelkin J, Findlay IM. Autonomy and orientation of entrepreneurial community pharmacists and

40. 41.

42. 43.

44.

45.

46.

47.

48.

49.

50.

51.

corporate pharmacy managers: a comparative study. Available at: http://ojs.acadiau.ca/index.php/ASAC/ article/viewFile/610/519, 2009. Accessed 19.12.10. Barney JB. Firm resources and sustained competitive advantage. J Manag 1991;17(1):99–120. Bueno E, Alberto Aragon J, Paz Salmador M, Garcia VJ. Tangible slack versus intangible resources: the influence of technology slack and tacit knowledge on the capability of organisational learning to generate innovation and performance. Int J Tech Manag 2010;49(4):314–337. Feldman MS. Resources in emerging structures and processes of change. Organ Sci 2004;15(3):295–309. Iyer S, Doucette WR. The influence of environmental attributes on the relationship between entrepreneurial orientation and performance in independent community pharmacies. J Pharmaceut Mark Manag 2003;15(2):25–46. Salverson SM, Murante LJ. Clinical training program based on a practice change model. Am J Health Syst Pharm 2002;59:862–866. Kaiser Family Foundation. Prescription drug trends; Available at: http://www.kff.org/rxdrugs/upload/ 3057-08.pdf. Accessed 24.05.11. Webster L, Spiro RF. Health information technology: a new world for pharmacy. J Am Pharm Assoc 2010;50(2):E20–E31. Warholak TL, Rupp MT. Analysis of community chain pharmacists’ interventions on electronic prescriptions. J Am Pharm Assoc 2009;49(1):59–64. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Hopp TR, Aslani PA. Understanding practice change in community pharmacy: a qualitative study in Australia. Res Social Adm Pharm 2005;1:546–564. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Aslani P. Practice change in community pharmacy: quantification of facilitators. Ann Pharmacother 2008;42(6):861–868. Clark BE, Mount JK. Pharmacy service orientation: a measure of organizational culture in pharmacy practice sites. Res Social Adm Pharm 2006;2:110–128. Scahill SL, Carswell P, Harrison J. An organizational culture gap analysis in 6 New Zealand community pharmacies. Res Social Adm Pharm, in press. Corrected proof, Available online 23 July 2010, ISSN 1551-7411, doi:10.1016/j.sapharm.2010.06.002.


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Appendix 1 EO dimensions and adequacy of resources measure items EO 1. Proactivenessa 1. Our pharmacy usually takes action in anticipation of future market conditions 2. We try to shape our business environment to enhance our presence in the market 3. Because market conditions are changing, we continually seek out new opportunities 2. Risk takinga 1. Taking gambles is part of our strategy for success 2. We take above-average risks in our business 3. Taking chances is an element of our business strategy 3. Autonomya 1. New service ideas suggested by employees are acted upon by decision makers 2. Management approves of independent activity by employees to develop new services 3. Identifying new business opportunities is the concern of all employees 4. Work ethica 1. We consider ourselves as having high motivation toward work 2. Our employees are a group of hardworking individuals 3. At our pharmacy, we are very ambitious about our work Resources 5. Adequacy of resourcesb How adequate are. 1. Skills to provide services 2. Financial resources to implement new services 3. Expertise to develop new services 4. Staffing levels to provide new services 5. Resources to obtain payment for services 6. Skills to market services Scored on a 5-point scale for the pharmacist’s agreement with each statement where 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, and 5 ¼ strongly agree. b Scored on a 5-point scale for the pharmacist’s assessment of each resource where 1 ¼ poor, 2 ¼ fair, 3 ¼ good, 4 ¼ very good, and 5 ¼ excellent. a