Harvey A.K. Whitney Award Lectures

Leadership: Successful Alchemy

“I would prefer to spend… time discussing briefly our greatest need in hospital
pharmacy – leadership.” This is a quote from Gloria Niemeyer Francke’s 1955
Whitney address, which is still appropriate. Leadership is just as critical today to
our future success as it was in 1955. As a profession we need to thrive in order to
continue to protect patients from medication harm and ensure the desired therapeutic
outcome so they can resume their lives.

Recent survey data indicate that in the next decade we will need 4000-5000 new
directors of pharmacy and middle managers, primarily because current leaders will be
retiring. These numbers do not take into account the expected expansion of health
care needs as the baby boomers age. These same survey data indicate that only 44% of
the pharmacy directors who will be leaving their position have a staff member who they
would recommend to replace their position when they leave. It is unclear if these
pharmacists would accept the position. Only 30% of current practitioners indicated any
interest in seeking a leadership position during their career; however, 62% of pharmacy
students indicated an interest in pharmacy leadership.

If an organization cannot fill a vacant pharmacy leadership position with a
pharmacist, it will likely fill it with a materials manager, a nurse, a physician, an M.B.A.,
or an M.H.A., as it must have pharmacy leadership. Boards of pharmacy can only
require a pharmacist be identified as “in charge” and cannot dictate that the person be
the director. Would a non-pharmacist director of pharmacy be in the best interest of
patient care? I think not. This leadership gap needs to be viewed as a stimulating
challenge, not as dismal despair.

So how do we ensure that we will have enough pharmacist leaders for the future? We
cannot remain just innocent bystanders. I believe that every pharmacist is a leader.
There are “big L” leaders – those in formal leadership positions, such as director,
associate director, assistant director, supervisor, clinical coordinator, and operation
manager. However, every pharmacist is a “little L” leader in his or her practice or on his
or her shift, whether this is recognized or acknowledged. Some must be willing to take
the “big L” positions as they become available if we are to continue to have an adequate
supply of future pharmacist directors of pharmacy. This potential leadership crisis cries
out for commitment and involvement by each pharmacist.

Every day, all pharmacists make decisions that affect the way they think, live, interact,
react, and learn. Regardless of what we may believe, no one else leads us through life.
We must take the initiative. Leaders make decisions, provide direction, develop plans,
guide and nurture themselves and others, seek opportunities, and make choices. In the
absolute truest sense of the word, each of us is a leader, and everyone, at some point,
exhibits leadership. What we do with the opportunities presented to us determines what
kind of leaders we are.

Leaders have an inner drive, a passion, for what they do and for making things better.
Leaders realize that hard work, sacrifice, and persistence will allow them to achieve their
goals and dreams; they are uncompromised in their level of commitment and
continuously challenge the limits of their knowledge. They view change as a friend and
welcomed opportunity. Leaders are disciplined, patient, assertive, confident, and
accountable. Leaders know that nothing of value comes without being earned. Leaders
do not place their priorities on earning money, fame, or success; they lead because they
see a need and want to address it.

To demonstrate how every pharmacist is a leader, let us examine how we arrived at
our current level of health-system pharmacy services and practice.

Past leaders and their legacies

A sincere debt of gratitude is owed to past pharmacy leaders, many of whom were
“little L” leaders, who paved the way for us to provide our unique drug knowledge to
benefit patients. Obstacles had to be overcome, physicians and nurses and other allied
health professionals had to be convinced of the value of the pharmacist, and pharmacists
had to overcome their own self-doubt to show their value as an integral part of the
provision of high-quality patient care.

The significant contributions of our predecessors that highlight the evolution of the
specialty of hospital and health-system pharmacy are described below. These
contributions are divided into three areas: hospital pharmacy professional development,
innovations in drug distribution systems, and the pharmacist as a drug information
resource.

Hospital pharmacy professional development

Hospitals have not always had a pharmacist practicing onsite. Past leaders recognized
this need and began working full-time in hospitals. These practitioners soon had a need
for a community of like-minded pharmacists and thus formed a hospital subsection
within the American Pharmaceutical Association (APhA). They wanted to share their
experiences and learn from each other, so they developed continuing-education
programming specifically related to the evolving practice of hospital pharmacy. The
need for a central office soon became evident to the volunteer leaders, and, in the face
of much opposition, they formed a division of hospital pharmacy within APhA. In 1942
this section became the American Society of Hospital Pharmacists (ASHP), a separate
organization affiliated with APhA. At the same time, leaders in state and local areas
were developing similar groups to provide forums for leadership training, continuing
education, and sharing among themselves. These state and local groups have evolved
into ASHP-affiliated state chapters. Without ASHP leaders, ASHP’s Bulletin (journal),
minimum standards of practice, continuing-education programs (institutes), networking,
governmental affairs, and voluntary pharmacy leadership positions would not have
evolved.

At the University of Michigan Hospital, the director of pharmacy Harvey A. K.
Whitney Sr., whose contributions this award recognizes, developed a formalized
internship program to train future hospital practitioners. Coupled with the internship
program, formal classes in pharmacy education were taught in the new specialty of
hospital pharmacy. These internships evolved into very successful one-year residency
training programs. These programs received certificates and approval from ASHP, and,
through the efforts of the ASHP leaders, residency training standards were developed
and a formal accreditation process was established to ensure the uniform quality of these
programs. These residency programs have been instrumental in providing a cadre of
successful leaders and must continue to do so. The ASHP Resident Matching Program
was implemented to ensure fairness in programs’ selection of candidates for all residency
applicants.

In 1964, the “Mirror to Hospital Pharmacy: A Report of the Audit of Pharmaceutical
Service in Hospitals” was published. This reported the results of a comprehensive and
introspective study financed by a grant from the U.S. Public Health Service. The report
also included recommendations to and described the implications of hospital pharmacy
practice. Some of the recommendations have still not been achieved and are very
relevant. One such recommendation is

That the chief pharmacist take greater advantage of their degree of freedom and of
the cooperative attitudes existing in hospitals to plan and present dynamic, progressive,
and imaginative programs for the improvement of pharmacy service which will, at the
same time, improve the attitude of the professional staffs toward pharmacy.

Another major professional development was the clinical pharmacy consensus
conference commonly referred to as the Hilton Head Conference. This conference was
conducted under the leadership of ASHP and provided recommendations that legitimized
and stimulated the expansion of clinical pharmacy practice.

These former leaders, both “big L” and “little L,” were pioneers going into uncharted
territory, hospital pharmacy practice, and establishing it as a unique practice. This
pioneer spirit must be continued by current and future leaders. Thus, a leader is a
pioneer, a pathfinder, who continually faces the unknown, exploring new territories, and
dealing with unforeseen challenges.

Drug distribution system innovations

Once pharmacists were practicing in hospitals, they recognized the need to improve
how medications were distributed from the pharmacy to the patient care areas and better
utilize the pharmacist’s expertise to minimize patient harm from medication errors. These
past leaders provided the leadership to change the systems. The initial efforts were
several-fold: Move the medication stock bottles from the patient care areas to the
pharmacy; have the pharmacist receive and review a no-carbon-required (direct) copy of
the physician’s original order before sending only a patient-specific labeled supply, usually
three to five days’ worth, to the nursing unit; and create a patient-specific medication
profile that enabled the pharmacist to screen for allergies and drug interactions.

As more medications were developed by the pharmaceutical industry and administered
intravenously, it became evident that having nurses compound these medications did not
take advantage of pharmacists’ drug knowledge. Nurses would call the pharmacist and
inquire about the white cloudy solution that had appeared in the patient’s Buretrol. Thus,
leaders developed and implemented i.v. admixture programs. These innovations
stimulated the pharmaceutical industry to provide minibags and other needed packaged
items.

While the number of medication errors had been reduced with these system
improvements, they still occurred; former leaders experimented with “setting up” doses
for the nurses’ major medication administration times. Only individually packaged doses
in patient-specific labeled bins that each patient needed until the next cart exchange were
distributed. This process resulted in significant reduction in medication errors. Thus, the
unit-dose system was coupled with the i.v. admixture system to form the optimal drug
distribution system.

With these improvements in the drug distribution system came an increased workload
for pharmacy. Veteran leaders recognized that some nonjudgmental, routine functions
could be delegated to a trained pharmacy technician as long as a pharmacist provided
the final check before the medication left the pharmacy. Subsequently, on-the-job and
formal pharmacy technician training programs were instituted. To ensure the consistency
and quality of these training programs, ASHP developed training standards and an
accreditation process for pharmacy technician training programs.

Continuing the evolution of safer and more efficient drug distribution systems,
computerization was applied, which enabled the printing of labels and unit-dose cart-fill
lists, patient charging, and profile maintenance. Likewise, the application of automation,
such as unit-based cabinets, carousel technology, and total parenteral nutrition
compounders, has reduced order turnaround time and provided a safer system by
ensuring pharmacist review of physicians’ orders. Continuing improvements include
computerized prescriber order entry and bedside bar-code technology.

Each of these innovations significantly changed how physicians, nurses, and
pharmacists organize and process their work. Leading and managing these changes
required a great deal of fortitude and stamina from these leaders, and we owe each our
thanks.

The pharmacist as drug information resource

Past leaders realized that the pharmacist’s drug knowledge was only partially being
used through the innovations in the drug distribution system. As the number and
diversity of new medications increased, so did the need by physicians, nurses, and
pharmacists for specific drug-related information.

At the University of Michigan, Whitney compiled a drug information card file to help
him answer physicians’ medication-related questions. Under Donald Francke’s leadership
as the director of pharmacy at the University of Michigan, this drug information
resource evolved into the American Hospital Formulary Service (AHFS), making
unbiased drug information available in the patient care areas.

Larger hospitals developed an organized drug information center or service that
provided answers to specific medication-related questions from physicians, nurses, and
pharmacists. These services utilized the original, peer-reviewed medical and
pharmaceutical literature. Because the exact answer to a question was not always found
in the literature, pharmacists applied their knowledge and expertise to provide enough
information to resolve the patient-specific issue. Along with the development of these
services, the need evolved for a cadre of specially trained pharmacist drug information
specialists. Specialty residency standards were developed by ASHP, and programs were
implemented and accredited.

To ensure rational drug therapy, hospital-specific formularies were developed in
concert with medical staff and pharmacy and therapeutics committees. The initial
formularies allowed only the stocking of one product when multiple products were
available. A pharmacist was generally the committee secretary, and pharmacists
provided unbiased reviews of the peer-reviewed medical and pharmaceutical literature
regarding a medication for the committee’s consideration.

Past leaders recognized that they could assist physicians in selecting the best drug
products and monitoring the drugs’ effects if they were present when these decisions
were made. Pharmacists began to attend rounds with physicians and apply their drug
knowledge to optimize therapeutics. To prepare future practitioners, clinical pharmacy
classes and clerkships were integrated into formal pharmacy education, and students
participated with the clinical pharmacists in patient care rounds. These students
experienced firsthand the contribution that pharmacists make to patient care.

While innovations in the drug distribution system changed how physicians, nurses,
and pharmacists process their work, these innovations were tied to handling the actual
drug product. By branching into the provision of drug information only, these former
leaders risked their creditability and professional reputation. They
had high professional pride and gave selflessly of their time and talent to improve
pharmacy services.

The question is, what specifically did these “big L” and “little L” leaders do to achieve
these professional changes? I propose that these leaders used successful alchemy.

Leadership as successful alchemy

It is thought that alchemy developed in Egypt and China, with Alexandria generally
considered its center. The purpose of alchemy was to change base metals, such as lead,
into decay-immune gold and produce an elixir of longevity to cure disease and restore
youth. This practice was the forerunner of the science of chemistry. The key ingredient
in changing these metals into gold was the philosophers’ stone, which served as a
catalyst for the transmutation. A catalyst is often needed for a chemical reaction to work.
In a chemical reaction, the catalyst may be temperature, pressure, or a special ingredient
in a small but a critical amount. Without a catalyst, there may be no reaction. Without
the catalyst of pharmacy leadership, patients would not fully benefit from pharmacists’
unique drug expertise. Without the pharmacy leaders that came before us, our
profession would not be where it is today. In the pharmacy profession, leaders are the
alchemists or catalyst, and leadership is the philosophers’ stone that combines all the
components of health-system pharmacy into the most perfect pharmacy services,
equivalent to gold, on behalf of our patients. Leadership may appear like alchemy to
nonleaders, but there are very specific things that successful leaders do, all of which can
be learned.

What motivated this alchemy and is responsible for the evolution of health-system
pharmacy? What was the catalyst for the advances that have been made? In some cases,
it is “creative dissatisfaction” – when someone uses his or her unhappiness with the status
quo to bring about change, regardless of the ridicule or barriers that may be
encountered. Gloria Francke(1) indicated that a good leader “faces opposition creatively.”
Pharmacists would not be where they are today without past leaders and leadership
having been successful in taking the raw material, base metal, of pharmacists’ drug
expertise and developing and organizing services for the benefit of patients. Leaders,
both “big L” and “little L,” play an important role in the history of the profession.
Current and future leaders must continue this professional evolution through their
leadership.

Seven elements of leadership

The purpose of assuming either “big L” or “little L” leadership must be for honorable
reasons: improving pharmacy services on behalf of patients, helping pharmacy staff to
grow and develop satisfying careers, and more fully applying our unique drug
knowledge in every available opportunity across the continuum of care. Gloria Francke
stated that the leaders must operate not for themselves but for the profession; they “take
pay for their work, but they do not work for pay.” Leaders place purpose above personal
interest or purity of purpose. History is full of leaders who did not work for the best
interest of those they led.

There are seven key elements to leadership: (1) have a written work group vision and
mission, (2) work effectively to accomplish actual results, (3) persevere and persist, (4)
influence through attitude and approach, (5) work well with others, (6) lead oneself so
people want to work with the leader, and (7) invest in the future. A detailed description
of each element follows.
Have a written work group vision and mission. The power of a work
group’s written vision and mission can be compared to a lighthouse or foghorn. A vision
is a picture of the future that inspires the passion of the leader and staff. Lighthouses are
always visible or use foghorns during bad weather. Without a written pharmacy vision
and mission (the lighthouse), pharmacy staff can easily drift and lose focus.

Another way to think of this vision and mission is as a global positioning system
(GPS). With a GPS, you enter where you want to go, your vision and mission, and the
GPS determines the exact directions, goals, their accompanying action plans, and
timelines that you need to achieve to arrive at your chosen destination, your vision. The
GPS will give you advice along your route as you progress. As pharmacy staff progress
toward their desired future, the vision and mission provide them with direction and
goals, so no one gets lost or wastes time.

In developing the vision and mission, do not be afraid to dream the big dreams. It is
far better to have a large vision and never totally reach it than to have a small one and
achieve it. We pharmacists are often our own worst enemies with our self-limiting
dreams. Big dreams take no more effort than small dreams, yet the outcomes are
different. Every great accomplishment was once the “impossible dream” of someone
who simply refused to quit when the going got tough. Obviously, the pharmacy vision
needs to fit within each organization’s vision. It is important that all staff have input into
the vision and mission. They should be reviewed and updated frequently, perhaps every
two months. Employ the vision and mission in staff meetings and with individual staff
members to keep them in front of people, and ask staff members how they have recently
contributed to them. This exercise provides the recognition of individual staff
contributions on an ongoing basis, excites others, and gets them involved.

When the leader serves as the catalytic lighthouse, there is no question among staff
members regarding the pharmacy service’s direction. However, direction alone is not
enough for a successful leadership alchemy. There must also be the accomplishment of
actual results.
Work effectively to accomplish actual results. Successful leaders realize
that they, like gardeners, must constantly attend their pharmacy services garden.
Gardeners cannot expect a harvest if they do not plant the appropriate seeds and care
for them. Last-minute programs do not work in the garden environment. Leaders must
manage their time to achieve actual results, not just talk about the desired goals. Leaders
must constantly tend the garden.

How leaders get their work done affects everyone. Managing time is the challenge of
consciously establishing priorities, scheduling these priorities, and constantly answering
the question, what is the best use of my time right now? It is important not to get
overwhelmed by trivial e-mails and voice mails. Leaders must have a bias for action or
constant sense of urgency versus being constantly busy and not really achieving actual
results. Accepting outcomes that are less than perfect is the key to being productive in
leadership. Leaders must be willing to delegate all tasks that can be done by others and
reserve their time for those that they have the expertise to complete. Constantly asking,
what can be done to accomplish this task more effectively and efficiently, is leadership.
Leadership is maintaining a balance, so that no one person or task is neglected, such as
balancing time spent in an office with time out with the staff who are tending the
garden.
Persevere and persist. A persistent leader is one who has the strength of
bamboo, able to constantly bend and bounce back. This bending is required in dealing
with differing circumstances, adjusting to changes, overcoming adversity, and meeting
every challenge with courage and compassion. Another way to envision this leader is a
palm tree that is still standing after a hurricane has passed through. This leader always
gets up one more time and does whatever it takes to achieve the goals and move the
pharmacy toward its vision and mission.

The leader needs to remember that the strongest oak of the forest is not the one that
is protected from the storms and hidden from the sun. It is the one that stands in the
open where it must struggle for its existence against the winds and rains and scorching
sun. Being a leader is not necessarily easy, but the outcome of better patient care is
worth the effort. Leaders cannot change the direction of the wind; leaders must adjust
their sails.

The key to persistence is consistently having multiple plans for achieving success, and
never giving up. Strategies and methods for reaching the necessary results may need to
be adjusted or changed, yet leadership is understanding that being consistent in the
desired outcome is extremely important. Power comes from just making steadfast
progress through actual results.
Influence through attitude and approach. Being an influence catalyst
means that staff would follow the leader through fire because of the leader’s positive,
optimistic, and enthusiastic attitude. The wisest leaders’ approaches are like water, fluid
yet infinitely strong, able to reach their destination and overcome the rocks along the
way. Leaders know they are clearly responsible and hold themselves accountable for
their work group’s success. These leaders accept being in charge and continually
demonstrate initiative. There is an earned trust between the leader and his or her staff.

If someone has not told the leader lately that his or her ideas are crazy, the leader has
not been doing much independent thinking. Problems are opportunities in disguise.
Successful leadership is seizing or making opportunities. Defeat is not failure. Failure is
when the leader lets defeat become final. There is never failure but significant learning,
and the leader must model this approach.

Placing blame and making excuses are not part of the leadership persona. Leadership
is not asking someone to do something that he or she would not do. Seeing challenges
as opportunities, replacing problems with solutions, and overcoming failure are essential
to successful leadership and organizational influence.
Work well with others. Successful leaders think of their staff as plants. To
bloom and thrive, staff need to be rooted in the rich soil of a nurturing work
environment. They must be watered with care and attention and warmed by the sunlight
of appreciation. Too many leaders treat their staff as cacti. These unsuccessful leaders
expect their staff to flourish in an arid, remote atmosphere. People tend to exceed
expectations when they are led by someone who cares about them and has their best
interest in mind.

Every leader should keep in mind that staff are like sticks of dynamite. The staff’s
power is on the inside. Nothing will happen until the fuse gets lit through an inspiring
vision and mission. Highly motivated individuals need rewards, recognition, and
responsibility. But most of all, each person needs to be needed. People need to know
that their contribution, their best effort, is truly valued.

Leadership is working to make daily tasks easier for all involved through effective
teamwork Leadership is viewing staff members as the department’s most valuable asset,
sincerely caring about them, and recognizing a job well-done. Celebrating staff
achievements, encouraging personal and professional development, and providing
growth prospects are part of being a successful and well-respected leader. The ultimate
test of leadership is the quality of those willing to be led. A leader helps staff to achieve
their full potential and provides growth opportunities.

In addition to working well with his or her staff, the leader represents the pharmacy
services throughout the organization and, as such, must positively contribute to the
organization’s teamwork. Helping other departments achieve their vision and mission is
critical to successful leadership alchemy.
Lead oneself so people want to work with the leader. Who the leader is
as a person establishes the work group culture. Culture is the tone and morale of the
work environment. Knowing yourself and understanding what drives your attitude and
emotions are the first steps to self-knowledge, self-control, and effectiveness. Effective
leaders are like the symphony conductor who combines the various instruments to
produce a work of art. Many different personalities, strengths, and weaknesses must be
taken into account by the conductor. The musicians are all experts with their
instruments but must play together to be truly successful. Achieving this synergy is the
conductor’s leadership role.

The most difficult leadership experiences become the crucible that forges the leader’s
character and develops the internal powers and the freedom to handle difficult situations
in the future. Leaders must always be a first-rate version of themselves instead of a
second-rate version of someone else. If the leader is not enjoying the journey, the
destination will be a disappointment. The successful leader must commit to excellence in
every task because others are influenced by his or her actions.

Leadership is exhibited by the type of people that others want to be around.
Leadership is about conducting oneself in such a manner that attracts others. Leadership
is knowing that our greatest battles lie within us and not in the external world.
Therefore, managing our behaviors, overcoming fears and discouragements, and turning
those into positive motivators are signs of leadership. Having a sense of humor is key
when leading departments, working with staff, and solving problems. Leaders know the
importance of mentorship and seeking mentors’ advice for ongoing personal and
professional growth.
Invest in the future. Successful leaders invest in the development of their staff,
students, and residents to prepare them to lead others. Leadership is taking an active
role in helping shape future leaders.

Leadership is sharing one’s expertise with others, publishing, teaching, speaking at
professional meetings, serving as a preceptor for students, and conducting residency
programs. Leadership is serving on committees, holding elected offices, and
participating in organizations. Leaders understand that their contributions are vital to
their profession and community. Leadership is not seeing these activities as a burden.

Closing thoughts

Pharmacists cannot stand by and let health-system pharmacies be led by
nonpharmacists.

If you question why things are a certain way and you are not satisfied with “that’s the
way we’ve always done it,” then forge a new path with answers that are more
satisfactory. If you do not know where to start, utilize your network of peers and
colleagues to discuss your ideas and create a plan. Look for opportunities to utilize your
talents and skills. The profession would not be where it is today without our past leaders,
and the profession cannot achieve its full potential without you.

I have been blessed during my career to have worked with numerous excellent
colleagues from whom I have learned more than I have given back. I want to
acknowledge the managers, staff, residents, and students that I had the pleasure to know
during my time at Ohio State, Kansas, and Stanford universities. A special thanks to all
the colleagues who have become personal friends through my involvement in local,
state, and national professional organizations. I want to give a special thanks to three
mentors: (1) Clif Latiolais, Ohio State director of pharmacy, who showed me what could
be done with progressive pharmacy services and involvement in professional
organizations, (2) Harold Godwin, director of pharmacy at the University of Kansas, who
gave me a chance to learn to be a leader, and (3) Gloria Francke who from afar
demonstrated that a woman could be successful in a male-dominated profession. One
final thank you to Richard Dewayne Caldwell, my associate director at Stanford, without
whom I could not have survived being a director of pharmacy. Thank you.

***

Any references cited in this lecture are available in the PDF version.

Originally published in Am J Health-Syst Pharm. 2006; 63: 1497-1503.
© 2006, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.

***

Any references cited in this lecture are available in the PDF version.

Originally published in Am J Health-Syst Pharm. 2006; 63: 1497-1503.
© 2006, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.