1. CANDIDATURA AO PRÉMIO DE INVESTIGAÇÃO CIENTÍFICA
PROFESSORA DOUTORA MARIA ODETTE SANTOS-FERREIRA
Does a full-time ward-
based clinical
pharmacist increase the
quality of care and
improve the value for
money in Paediatrics?
Redesigning, monitoring and evaluation of
health services
Sílvia Figueiredo

2. Title of Project
Redesigning, monitoring and evaluation of health services
Does a full-time ward-based clinical pharmacist increase the quality of care and
improve the value for money in Paediatrics?
Project Investigator
Sílvia Maria dos Reis Figueiredo - Farmacêutica licenciada pela Faculdade de Farmácia da
Universidade de Coimbra; Inscrita na Ordem dos Farmacêuticos na Secção Regional de Lisboa
com Carteira Profissional 15173 e Sócia L-10420
Contact
962404597
silviamrfigueiredo@gmail.com
Project Team
Sílvia Figueiredo – Farmacêutica licenciada pela Faculdade de Farmácia da Universidade de
Coimbra
Carolina Brinca – Farmacêutica licenciada pela Faculdade de Farmácia da Universidade de
Coimbra
Academic and Clinical Supervisor
Catherine Duggan – Director of Professional Development and Support at the Royal
Pharmaceutical Society of Great Britain; Associate Director for Clinical Pharmacy, Development
and Evaluation for East and South East England Specialist Services (NHS); Director of Academic
Department of Pharmacy, Barts and The London NHS Trust; Senior Clinical Lecturer, School of
Pharmacy, University of London;
(United Kingdom)
Contact
Telephone: 020 7572 2358
E-mail: catherine.duggan@rpsgb.org
Clinical Co-supervisor
Monica Kan – Senior Directorate Pharmacist, Women´s and Children´s Services at Barts and
The London NHS Trust (United Kingdom)
Hetal Kushwaha – Senior Pharmacist, Bailey Ambulatory and Connaught Wards, Women´s and
Children´s Services at Barts and The London NHS Trust (United Kingdom)

3. Start Date
October 2005
Completion Date
July 2006
Project undertaken as part of an academic qualification
Erasmus Internship Project;
Master Degree in Pharmaceutical Sciences;
Master´s Thesis in Clinical Pharmacy
Funded by
Erasmus Scholarship
Higher Education Institutes involved
Department of Practice and Policy, School of Pharmacy, University of London
Academic Department of Pharmacy, Barts and The London NHS Trust
Departamento de Farmacologia e Farmacoterapia, Faculdade de Farmácia Universidade de
Coimbra
Non-academic project partner
Women’s and Children’s Services, Royal London Hospital, Barts and The London Trust NHS
Trust
Acknowledgements
The author acknowledges all the staff in the academic pharmacy department at Barts and the
London NHS Trust, especially Catherine Duggan, Monica Kan and Hetal Kushwaha, for their
assistance, guidance and support. The author also acknowledges her colleague Carolina Brinca
for her hard work during all stages of the project.

4. Conflict of Interest Statement
The author certifies there is no conflict of interests. The project was undertaken as part of an
academic qualification and entirely funded by an Erasmus Scholarship.

5. Research, Development and Innovation - Challenges, opportunities, a chance to
make a difference
“Is it possible to increase the quality of health care provided against a backdrop of
tightening budgets?” (National Institute for Health and Clinical Excellence)
Redesigning, monitoring and evaluation of health services
Does a full-time ward-based clinical pharmacist increase the
quality of care and improve the value for money in Paediatrics?
BACKGROUND AND RATIONALES
As demographic change and financial pressures combine to create challenging times
for health care system, many aspects of the service have been looked in order to
induce a more rational use of resources, services and control of expenditures,
providing better and more efficient services.
In doing so it is required explicitly to take into account both clinical effectiveness and
cost-effectiveness.
Redesigning Health Services: Pharmacists as a Means of Cost Containment
Medicines are a central component of healthcare. The use of medicines is the most
common and the most important therapeutic intervention carried out in the NHS.
As the patient medications represent one of the single large expense categories for
NHS Trust´s and foundation trusts’, this is the area where efficiency savings are need
to be made, finding cost reduction opportunities, without compromising patient care or
clinical quality.
Significant quality improvements for patients and reduced costs can be achieved if
medicines are managed across the whole health economy.
The evidence suggests there is the potential to make significant efficiency savings and
improvements by optimizing the medicines management services and making better
use of hospital pharmacy staff.
As the medicines becomes more powerful (and potentially dangerous), and the
pharmacists are experts in medicines, professional practice guidelines recommended
that pharmacists need to be integrated into the clinical team, closer to the patient
centered care.

6. There is evidence that through the implementation of clinical pharmacy programs that
includes standards and guidelines for best practices and the identification of medication
targets of opportunity to reduce costs (from product procurement to medication
administration and all areas between), the clinical pharmacy service contributes to help
organizations meet the twin challenges of providing high quality care to patients and
the public while also saving money and resources.
The objective of clinical pharmacy practice is to optimize patient outcomes, making the
most effective, efficient and economical use of medicines.
Hospital pharmacists have shown clearly their benefit in patient care by intervening to
improve the cost-effective use of medicines.
But despite the growing evidence supporting the pharmacist’s contribution to patient
care, many hospital services have not taken full advantage of this vital resource.
Monitoring, Evaluation and Research of Health Services
In this era of cost containment, hospital administrators are likely to fund only those
programs and services that clearly improve patient care, reduce costs and that
represent a cost-effective use of public money and staff time invested.
To demonstrate the impact on a hospital budget and to justify a position or service,
research, monitoring, evaluation and documentation of improvement and generation of
a cost-savings report is essential.
Pharmacy Practice Research
Pharmacy leaders are constantly under pressure to justify both existing and expanded
clinical pharmacy services. The research and the published evidence of the value of
clinical pharmacy services are important resources that pharmacy leaders can use to
justify pharmacist led programs that improve clinical outcomes while also improving net
revenue by reducing overall expenses or augmenting gross revenue.
The King's Fund defines pharmacy practice research as "research which attempts to
inform and understand pharmacy and the way in which it is practiced, in order to
support the objectives of pharmacy practice and to ensure that pharmacists' knowledge
and skills are used to best effect in solving the problems of the health service and
meeting the health needs of the population".
Health Service Evaluation
The decisions about resource allocation to health care services will increasingly be
based on Service Evaluation.
Health Service Evaluation is “A set of procedures to judge a services merit by providing
a systematic assessment of its aims, objectives, activities, outputs, outcomes and
costs.” (NHS Executive, 1997)

7. Service Evaluation is a key component of any strategy to develop resources to improve
health. It can ensure that resources are being used on the most cost-effective
interventions, thereby maximising the available resources to achieve the most benefit.
Evaluation can also indicate where changes may need to be made to a service, in
order to improve its effectiveness. For this reason, evaluation is usually considered at
the planning stage of any activity aimed at improving health.
Service Evaluation can demonstrate which services are effective and efficient, how to
achieves maximum effects for minimum costs.
A well-designed evaluation will provide valuable evidence both of successful outcomes
and of good project management, or will indicate the opposite. Demonstrating
acceptable outcomes and/or management action will make it easier to obtain additional
resources from the funders to develop or change the service. Findings will also
demonstrate to potential new funders or partners that the service is a good investment.
Monitoring, Service Evaluation and Research are important aspects of Pharmacy and
essential in providing evidence that pharmacy delivers services that are effective, high
quality and value for money.
AIM AND OBJECTIVES
The overall aim of the project was to monitor, evaluate and research the impact of the
proposal of a new pharmacy service model implemented – a full-time ward-based
clinical pharmacy service in Paediatrics.
To achieve this, the objective set was: to compare the pharmacist’s performance
between two levels of clinical pharmacy services – 1 hour a day service (control group)
and a full-time service (study sample) by measuring clinical pharmacy activities and its
outcomes.
METHODS AND MATERIALS
1. Literature review of national recommendations and local guidelines for each
stage of patient’s journey;
2. Development of a data collection form;
3. Pilot study;
4. Data collection;
5. Statistical Package for the Social Sciences (SPSS) version 13 was used for
data entry and analysis.
6. A final report was written for dissemination of the findings and
recommendations

8. KEY FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
Key Findings
 The full-time ward–based pharmacy service provided an opportunity for several
clinical pharmacy interventions.
 Pharmacist activities and interventions included: accurate medication history;
clinical prescription review (endorsements and amendments in Inpatient
Prescription); correcting/clarifying orders; providing medicines information;
suggesting alternative therapies; detection and prevention of drug reactions and
interactions; prevention of potential medication errors; therapeutic drug
monitoring; participation in multidisciplinary ward rounds; supporting
prescription decision making; therapeutic discussion with medical and nursing
staff; participation in discharge planning; information for ongoing care
(communication to the 1st care and patient education about their current
medication and medication to take home); review problems arising from
dispensing; liaise with the pharmacy compounding service or CIVAS for items
required; liaise with Drug Information Service for any information not readily
resourced; liaise with pharmacy dispensing services for timely dispensing of
discharge medication; ensuring the use of PODs during patient stay; supporting
the medical and nursing staff in the use of unlicensed medicines.
 As a result of these clinical pharmacy interventions, preventable adverse drug
reactions, prescribing errors, length of hospital stay and drug-related re-
admissions were reduced, thereby yielding savings related to cost avoidance.
 Cost-savings interventions comprised a small percentage of clinical pharmacy
interventions, but they generated substantial savings. Interventions relating to
CIVAS (Centralised Intravenous Additive Service) medication lowered costs of
care without adversely affecting clinical outcomes. During 10 days of the study
period, the pharmacist ordered CIVAS medication twice, which represented a
therapy cost savings of £957.03.
Conclusions
The study concluded that re-designing the pharmacy services around the patient
through having a full-time ward-based pharmacist on Paediatrics has not only benefited
the patient through a reduction in drug related incidents and faster discharge
prescriptions, but also, the drug budget by saving drug costs through improved
medicines management.
Therefore, it was concluded that a full-time ward-based pharmacist is an important and
cost-effective member of a Paediatric health care team.

9. Recommendations
1. Clinical pharmacist interventions in the Pediatric wards resulted in significant
effect on clinical and economic measures and can therefore be suggested as a
routine practice. The participation of a clinical pharmacist on a multidisciplinary
care team should be a standard of care.
i. Pharmacist’s presence and participation in multidisciplinary ward rounds
and meetings is the most effective method of contributing to the quality
of patient care. The presence and participation at multidisciplinary ward
rounds and meetings provides an opportunity for a pharmacist to have a
current knowledge of patient clinical situation and about the latest
evidence regarding disease and medicine state management, which
leads to valuable clinical interventions with positive impact in clinical
results and on economic outcomes.
ii. The complexity of the medication use system necessitates a
comprehensive and specialized knowledge base, and pharmacists are
best suited to have the knowledge, skills, and abilities required for the
proficient medicines management at all levels.
iii. In collaboration with other members of the patient care team, pharmacist
share the responsibility for patient care outcomes and for saving money
and resources, not just by providing basic dispensing functions and drug
information services, but by solving patient drug-related problems and
by making decisions regarding drug prescribing, monitoring, and drug
regimen adjustments.
2. Pharmacists need to continue to generate evidence for the impact they have on
the quality and cost-effectiveness of patient care and publish findings on the
effectiveness of their roles.
i. Documentation of clinical interventions can provide evidence of the
impact of clinical pharmacy services on patient care.
ii. Thus, all the activities that potentially improve the quality of patient care
or result in clinical and/or economic outcomes should be documented.
IMPLICATIONS OF THE FINDINGS AND CONCLUSIONS FOR PHARMACY
PRACTICE AND FUTURE DIRECTIONS
Because of the findings, conclusions and recommendations of this study, the pharmacy
and hospital administration agreed to provide a full-time ward-based clinical pharmacist
to round in Paediatrics on a regular basis. This approach is considered to be more cost
effective than using a one hour a day clinical pharmacist for daily rounds.

10. Moreover, the new implemented service made evidence of a better use of the
pharmacist’s skills and by all the characteristics that presents, Paediatrics proved to be
an exceptional area where the investment in clinical pharmacy services should be a
priority.
This project may also be used to educate other health providers, administrators, and
developers of health care policy on the role of pharmacists and pharmacy services in
the health care system.
HOW DOES THE PROJECT ACHIEVE THE OVERALL AIM OF THE PROFESSORA
DOUTORA MARIA ODETTE SANTOS-FERREIRA SCIENTIFIC RESEARCH PRIZE?
A good way to improve performance is to share knowledge and replicate
successes from one place to another.
This study generated new knowledge and points to innovation, good pharmacy
practice, promising practice, lessons learned and success stories in the full cycle of
medicines management and in the pharmacy profession.
Therefore, the project can contribute as a catalyst for change. The application of
this data and the collation of the generated evidences enables ultimately inform
policy and practice relating to pharmacy and pharmaceutical services. It also
allows the sharing and showcasing of good pharmacy practice and the increased
knowledge exchange and learning in pharmacy and pharmaceutical sciences.
Increasingly inputs and studies such as this are needed, whether these are case
studies, audit data, service development, service evaluation or research findings, for
the delivery of professional advice and support as well as professional development,
science and research strategies.
The documentation of the economic value of clinical pharmacy interventions in addition
to clinical and humanistic outcomes is absolutely vital for ensuring the implementation
and the sustainability of a clinical pharmacy service. Economic analysis of clinical
pharmacy services is necessary to ensure that health care administrators and payers
understand the savings or benefits that can be achieved through the implementation of
these services. Moreover, this may significantly improve the ability of other pharmacists
to implement similar services in other health care venues.
Valuable conclusions and recommendations emerged from the study for pharmacy
professional development and support that can also be extrapolated to Portuguese
Pharmacy Practice in the current context of our Health Care System.
Pharmacists are in a unique position to be able to identify clinical situations where
there is lack of evidence for a specific practice.
Furthermore, by evaluating their services, pharmacists will be able to provide evidence
that their priorities for service development and patient care are justified. The

11. importance of dissemination of any evaluation work cannot be over emphasised. It is
only by sharing our learning that we can improve services.
The success of the implementation of a new pharmacy service model such as this
depends on pharmacists understanding the importance of documenting their
interventions and of contributing to the pursuit of evidence-based practice. When
intervening as part of their clinical pharmacy services, pharmacists did not necessarily
save lives but did bring about changes, which directly increased the quality of patient
care and contributed to a significant financial gain. By undertaking this study, the value
of pharmacists’ clinical expertise in Paediatrics has been established.
“The future success of pharmaceutical care models is increasingly dependent on
our ability to provide compelling evidence of the value of clinical pharmacy
services and to articulate that value to financial decision makers.” 2002 Task Force
on Economic Evaluation of Clinical Pharmacy Services of the ACCP