PHARMACIST ACCOUNTABILITY FOR PATIENT OUTCOMES

To affirm that pharmacists are obligated by their covenantal relationship with patients to ensure that medication use is safe and effective; further, 

To declare that pharmacists, pursuant to their authority over a specialized body of knowledge, are autonomous in exercising their professional judgment and accountable as professionals and health care team members for safe and effective medication therapy outcomes; further, 

To encourage pharmacists to define practices and associated measures of effectiveness that support their accountability for patient outcomes; further,

To promote pharmacist accountability as a fundamental component of pharmacy practice to other health care professionals, standards-setting and regulatory organizations, and patients.

Rationale

The Council, Board, and House agreed that a clear, succinct policy communicating the interrelationship of authority and autonomy with accountability for outcomes, good or bad, is needed. The policy should distill and define ASHP’s stance on accountability and draw on concepts implicit in current ASHP policy documents. The Council, Board, and House recognized that authority, autonomy, and accountability are inseparable components of professional practice. Without accountability, the pharmacy profession cedes the ultimate authority for decision-making in matters of medication therapy to prescribers, calling into question whether pharmacy is, in fact, a profession. 

The pharmacist’s covenantal relationship with patients is described in the Pharmacist’s Oath, to which all pharmacy students profess, and which states in part:

• I will consider the welfare of humanity and relief of suffering my primary concerns.
• I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.
• I will embrace and advocate changes that improve patient care.

The attributes of professional status are defined by sociological, ethical, and legal expectations in literature on this subject. Those commonly cited include:

• Work is based upon the mastery of a complex body of knowledge and skills; a practice founded upon this knowledge is used in the service of others. 
• Members are governed by codes of ethics and profess a commitment to competence, integrity, and … promotion of the public good within their domain. 
• A social contract exists in which, in exchange for these commitments, society recognizes the profession’s authority over the knowledge base, autonomy in practice, and the privilege of self-regulation.
• The profession’s members are accountable to those served and society.

Despite strong advocacy by pharmacy thought leaders and a wealth of evidence in its support, the precept that pharmacists are accountable for medication therapy outcomes is not widely accepted by other health care disciplines, nor is it broadly integrated into pharmacy practice. Moreover, many pharmacists may be ambivalent about assuming a role that holds them to high standards of practice and makes them answerable for the welfare of patients. 
Accountability is implicit in many ASHP policy documents, most notably in the ASHP Statement on Pharmaceutical Care:

Pharmaceutical care is not a matter of formal credentials or place of work. Rather, it is a matter of a direct personal, professional, responsible relationship with a patient to ensure that the patient’s use of medication is optimal and leads to improvements in the patient’s quality of life.

The pharmacist’s authority over and expertise in use of medications are supported by the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation Interpretive Guidelines, which establish a definition and expectation for pharmaceutical care:

Pharmaceutical care is defined as the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life while minimizing patient risk.

The Statement on the Future Vision of Pharmacy Practice from the Joint Commission of Pharmacy Practitioners (JCPP) is explicit in its expectation for pharmacist autonomy and accountability and states in part:

How Pharmacists Will Practice. Pharmacists will have the authority and autonomy to manage medication therapy and will be accountable for patients’ therapeutic outcomes. In doing so, they will communicate and collaborate with patients, care givers, health care professionals, and qualified support personnel. As experts regarding medication use, pharmacists will be responsible for rational use of medications, including the measurement and assurance of medication therapy outcomes…. Working cooperatively with practitioners of other disciplines to care for patients, pharmacists will be … valued patient care providers whom health care systems and payers recognize as having responsibility for assuring the desired outcomes of medication use.

The JCPP vision statement encompasses these attributes and clearly illustrates the direction that the pharmacy profession must take. In particular, the Council, Board, and House confirmed that pharmacist accountability is a profession-defining issue that must be urgently addressed, recognizing that the policy is at most a starting point for the transformation that needs to take place in order to realize the JCPP vision. 

The Council stated that unless the pharmacy profession commits to actions that translate the policy into practice, pharmacists are at risk of becoming irrelevant. As changes brought about by health care reform are implemented to add value to health care and reduce costs, the extensive training and high salaries of pharmacists cannot be justified if, as noted by the 2007 Council, “pharmacists are responsible and held accountable only for the acquisition, storage, and dispensing of medications.” 

The Council called on ASHP to be fearless and persistent in promoting and establishing the JCPP vision within the profession. The Council also recommended that ASHP use its influence to create the “pull” for accountability in pharmacy practice by establishing an expectation of pharmacist accountability by other health care providers, standards-setting and regulatory organizations, and payers.