How P&T Committees Can Be Effective Change Agents: Part 1

In medicine today, change may come quickly or slowly, episodically or constantly. It may come with difficulty or relative ease. Leading change is part of a pharmacy & therapeutics (P&T) committee’s responsibility. Committees change in response to the review and implementation needs of new therapies and technologies. They change based on new members who bring different

sets of skills and personal experiences, and they change to be more effective. They must continually adjust and refine how they incorporate evidence-based decision making into formulary development and implementation.

P&T committees routinely drive formulary changes and medication use management initiatives. The decisions P&T committees make often result in changes in clinical prescribing and practice as well, which can affect the care given to millions of patients.

Effective change agents need patience, energy, and leadership skills. They also must recognize that change may be slow and difficult. In a landmark article published in 1995, Harvard Business School Professor John Kotter reviewed the necessary factors for a successful transformation effort.¹ In this first of 2 articles on the subject, I review Professor Kotter’s approach and apply some of his principles to a successful P&T committee process. In the next issue, I will provide an additional perspective on P&T committees and change.

Professor Kotter provides reasons why the transformation process may fail. I focus on the reverse: the ingredients in a successful P&T process. The following factors are important in leading change.

Establish a Sense of Urgency

To lead effective formulary or medication use management changes, all P&T committees must establish a compelling sense of urgency, typically around issues of efficacy, quality or safety, or affordability. At its core, a P&T committee’s work is about creating more value for members’ premium dollars, while championing safe medication use and quality care. Frequently, that sense of urgency is communicated by the CEO and medical director. Their call for change in the face of rising healthcare costs and the worsening problem of the uninsured can help a P&T committee drive changes in prescribing.

A sense of urgency reinforces the importance of formulary management and medication safety. It promotes a committee’s work as essential to both the patient’s and the organization’s success, and creates an environment more conducive to successful transformation. Pharmaceutical and other healthcare manufacturers should begin their drug or technology research efforts with an understanding of the compelling needs that will drive P&T committee decision making and seek to develop products that can address those needs.

Create a Powerful Guiding Coalition

The composition of the P&T committee is critical. Because P&T committees drive changes in physician prescribing or changes in medication use, the credibility, reputation, influence, and “power” of the committee membership cannot be underestimated. As a P&T committee chair, I have always invited members not only because of their clinical skills and experience in evidence valuation, but also because of their reputations for excellence in the medical group. Taking the concept further, when I have encountered resistance to a medication management change or formulary withdrawal, I often have referred to my guiding coalition—my committee members—in leading the change. “Dr X and Dr Y are on the committee and are as concerned about this issue as I am.”

Have a Clear Vision

Clearly articulating the picture of a brighter future is fundamental to the work of a P&T committee. Explaining how a formulary change creates value for patients or creates savings that can be reinvested in other important ways to improve patient care is essential to effective change management.

The most powerful message formulary leaders can communicate is the vision of a safe and high-quality formulary that improves patient outcomes and avoids harm, as well as making healthcare more affordable. This message is becoming increasingly important as patients, employers, healthcare providers, and health plans look more closely at clinically appropriate therapies that may also have known risks. Citing the work of the Institute for Safe Medication Practices, a recent article identifies general steps being taken in the healthcare community to reduce the risk of harm.² It mentions initiatives at specific hospitals to ensure appropriate use of some high-benefit, frequently used drugs that may cause harm if used incorrectly (eg, heparin, insulin, intravenous opiates, warfarin, methotrexate).

In my experience, this vision resonates strongly with medical group and pharmacy staffs. We all want to feel important and involved in work that contributes to a better tomorrow. We want to be able to assure our patients and employers that we are anticipating and preempting the possibility of untoward results in treatment.

Communicate the Vision by a Factor of 10

Relentless communication with medical groups on the role of the P&T committee and the vision of affordable, safe, and effective pharmaceutical care is necessary to lead formulary and medication use management changes. This communication also is critical in helping physicians explain to patients—and plan management explain to employers—how the system is working at all times to achieve high-quality and cost-effective care.

Establishing the context for the change and naming the desired outcome are the work of both the P&T committee chair and the committee members. Making these expectations clear to committee members early on enables explicit discussions and member skill development, and amplifies the voice of the chair, often by a factor greater than 10. Clear and concise talking points that articulate the goals and direction of a P&T committee’s work—talking points that are reiterated through many channels of communication—are necessary to lead the kind of transformative change prescribers often are asked to undertake and patients and employers often are asked to accept.

Conclusion

Members of P&T committees all have been changed, lead change, and have a future filled with change. The work with regard to formulary and medication use management is in many ways about leading change in response to new information and creating a better tomorrow—for colleagues at work, colleagues in the larger prescribing communities, and most importantly, for patients. Understanding the factors necessary for successful change management will make this work more satisfying and rewarding, and make us more effective in the work ahead.