City of Hope: Adapting Pharmacy Roles With an Eye Toward Retention

The “great resignation” has hit institutions large and small, and even one of the nation’s leading cancer research and treatment centers is not immune.

So, when City of Hope National Medical Center, centered in Duarte, California, found itself struggling to attract and retain clinical pharmacists, a rethinking of their role was in order, according to Wafa Samara, PharmD, chief pharmacy officer, City of Hope Pharmacy Enterprise, and Sepideh Shayani, PharmD, BCOP, executive director of pharmacy enterprise, City of Hope Pharmacy Enterprise.

Samara and Shayani offered an overview of how City of Hope tackled its pharmacy retention challenge on Friday during the Association of Community Cancer Centers 39th National Oncology Conference, which concluded in West Palm Beach, Florida. Several Friday sessions focused on staffing issues, which attendees identified as a top problem during a session on Thursday.

Samara introduced the audience to City of Hope’s 100-year-old history and mission; the health system, now expanded beyond its southern California base, is a National Cancer Institute-designated Comprehensive Cancer Center and part of the National Comprehensive Cancer Network. It attracts top talent to be sure—scientists have pioneered advances in stem cell transplants and chimeric antigen receptor (CAR) T-cell therapy.

But as Shayani noted, all that requires the work of 250 oncology clinical pharmacists, and, “they are a rare breed.”

“What we have been seeing over past several years is a trend of highly trained pharmacists making a decision to choose alternate career paths—not always in patient care,” Shayani added.

City of Hope, she said, “recognized a need for us to optimize our patient care model,” to allow pharmacists to work at the top of their license and, where possible, to engage in clinical activities—work that keeps pharmacists engaged and retains them.

This would require an overhaul of the pharmacy department structure, which Shayani described as “a beautiful challenge for us.”

City of Hope hires both clinical pharmacists and pharmacy technicians; the former can work in clinical activities or in operations, which involves administrative work and making medicines. The titles of most of these staff did not truly reflect the scope of their duties, she said.

In addition, City of Hope looked to research by the University of North Carolina on oncology pharmacists in academic medical centers; 44% of the respondents had been in their roles more at least 5 years, and 21% had been in their jobs 10 years. The research found that 60% of these staff open to alternative careers, and 23% were at high risk of attrition, meaning they were actively looking for a different job.

Notably, the survey found that clinical work increased job satisfaction and made pharmacists less likely to leave—a result consistent with what City of Hope had observed.

So, how could City of Hope respond? Samara outlined a road map for change, recognizing that “changing culture and care models is not a onetime event.”

• Step 1 was a gap analysis, which looked at how other organizations managed their oncology pharmacists.
• Step 2 created a new career ladder with more distinct job descriptions and responsibilities; those who wanted to remain in operational titles could do so, but those who wanted to focus on clinical activities could move into newly created titles.
• Step 3 involved communicating the restructuring plan to all stakeholders and getting the resources to make it work. This also involved creating pathways for internal staff to shift jobs. Some new hires would be needed.
• Step 4 will implement the restructuring plan, and “will go on for a long time,” Samara said.

Many elements are needed for restructuring to work, Shayani said. Besides creating new titles for the staff, City of Hope redeployed the numbers in ambulatory and inpatient areas and used technology to streamline operations, so that inpatient pharmacists could be with patients.

Collaborative practice agreements, which are permitted by California’s licensing board, allow pharmacists to prescribe and manage patients under certain conditions. This has opened the door for pharmacists to manage clinics and run point on a host of items, from oversight of medication toxicity to management of oral therapies, to dose adjustments and billing where appropriate. Pharmacists have taken on a medical oncology head and neck clinic and a multiple myeloma clinic, for example.

Working to the top of the license has allowed pharmacists to take on tasks that include handling transitions of care for in an allogenic stem call transplant clinic and provided opportunities to take greater roles in clinical research, including presentations at conferences. It’s also created opportunities for flexibility for work from home scheduling, Shayani said, which has helped City of Hope meet needs of parents with young children.

Finally, Samara said, the process has also examined how City of Hope can improve the diversity of its workforce. “We did not match the community we serve,” she said. An internship program that brought in students from underrepresented communities—on salary and with housing support—has just graduated its first cohort, she said; the hope is that these students will become future applicants for the residency program.

Samara said there are many lessons from the experience. “For us, we are successful because we got leadership buy in.” That meant the process received support throughout from the IT staff and other resources.

But staff engagement and culture change remain the biggest challenge. City of Hope held town hall meetings so that pharmacists would understand, “what’s in it for me?” And leadership must accept that some pharmacists will still leave, while others will stay.

“This is a journey, and we need to nimble,” Samara said. “We need to be ready to change and tweak as we go.”