Harvey a. K. WHitney Lecture Pharmacy practice model
The evolution and metamorphosis
of the pharmacy practice model
Paul W. abramoWitz
Am J Health-Syst Pharm. 2009; 66:1437-46
Evolution is generally defined as a Alvin Toffler,1 in his landmark and what I hope we may achieve in
book Future Shock, observed that the future.
ring over a prolonged period of “What joins [everyday matters] . . . time. Conversely, metamorphosis is is the roaring current of change, a The pharmacy practice model of
a dramatic change or even a rebirth current so powerful today that it 1974 and its evolution
occurring over a relatively short overturns institutions, shifts our
period. These forces have been in values and shrivels our roots.” He when I entered pharmacy school. I motion since the beginning of time wrote those words in 1970, when I will describe through my eyes what and throughout all human history, was using a rotary-dial phone. He the pharmacy practice model looked and those of us born in the middle of may not have been able to predict like at that time. After our trip down the 20th century have probably wit- that almost 40 years later, people memory lane, we will fast-forward to nessed more technological changes would be walking around with mini- than has any previous generation. computer “smart” phones, but he was clearly see the enormity of change Our pharmacy practice model has aware that changes were occurring at that has occurred. I will then speak both evolved slowly and changed an exponential rate. “Change is ava- rapidly. For many years, I had the lanching upon our heads and most hope to see in the pharmacy practice opportunity to participate in guid- people are grotesquely unprepared to model 35 years from now and how ing and stimulating practice model cope with it,” Toffler1 wrote, with the we might arrive there. change and have learned, painfully intention of raising people’s aware- at times, that change often must be ness of this phenomenon so that they model focused heavily on the dis-evolutionary as it works against cul- would not be shocked by the rapid tribution of medications. The vast I would like to explore with you pharmacists spent most of their time enough, we may see opportunities some of the evolutionary and meta- morphic changes in the pharmacy cians were present but limited in practice model that I have observed number and had little standardized Paul W. abramoWitz, Pharm.D., FaShP, is Interim Hospital Asso- edged for their assistance in manuscript preparation.
ciate Director for Professional Services and Chief Pharmacy Officer, Presented at the ASHP Summer Meeting, Village of Rosemont, IL, University of Iowa Hospitals and Clinics, Iowa City, and Professor and Assistant Dean, College of Pharmacy, University of Iowa, Iowa The author has declared no potential conflicts of interest.
Address correspondence to Dr. Abramowitz at the Department of Copyright 2009, American Society of Health-System Pharma- Pharmaceutical Care, University of Iowa Hospitals and Clinics, 200 cists, Inc. All rights reserved. 1079-2082/09/0802-1437$06.00.
Hawkins Drive, Iowa City, IA 52242 ([email protected]).
Donna Rossman, Joan Murhammer, and Mary Ross are acknowl- Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
Paul W. Abramowitz is Interim Hospital Associate Director for Professional Services and Chief Pharmacy Officer at the University of Iowa Hospitals and Clinics and Professor and Assistant Dean at the University of Iowa College of Pharmacy. He previously served as Director of Pharmacy at the Medical College of Virginia Hospitals and the University of Minnesota Hospitals and Clinics and as a faculty member at their colleges of pharmacy. He currently serves as the Treasurer of ASHP and previously served as ASHP President (1993–94). He has chaired the Iowa Board of Pharmacy, the University HealthSystem Consortium Pharmacy Council, and the board of directors of the Iowa Statewide Poison Control Center.
Abramowitz has actively combined practice, teach- ing, and research throughout his career. He has lec- tured and published extensively, focusing on the effect that quality pharmaceutical care can have on improving outcomes of care and reducing costs, developing care models, and redesigning pharmacy services. He received his bachelor’s degree in pharmacy from the University of Toledo and his doctor of pharmacy degree from the University of Michigan. He completed his residency at the University of Michigan Medical Center.
Abramowitz was a recipient of the John W. Webb Lecture Award in 2000.
drug therapy by starting pharma-cokinetic services. With the market-ing of many new antibiotics and an increasing recognition of bacterial degree, outside of California, existed resistance, some pharmacists began cation between the pharmacist and only as a limited postgraduate pro- gram. One type of residency, one in information pharmacists introduced dominately occurred by telephone. hospital pharmacy, was accredited drug-use evaluations for popula-The unit dose system, pharmacy- Therapeutic decision-making began to apply cost-effectiveness into information centers existed in only a in the hospital was simpler, though medication selection and used it to small number of hospitals. Pharmacy much new information about phar- information systems were rare, and macodynamics, pharmacokinetics, Polypharmacy and adverse drug ef-automation was all but nonexistent. drug interactions, and adverse drug fects were more frequently being Virtually all patient records were pa- effects was becoming available. It recognized and managed. At the per records, not readily accessible to was an exciting time in pharmacy, University of Michigan, I observed the pharmacist.
with the practice model evolving in pharmacists attending rounds with Compared with pharmacy today, all sites of care. Physicians more fre- relatively few drugs were available. quently called pharmacists to obtain surgical teams. In 1974, the drugs available to treat in-depth information about drugs. The complexity of i.v. therapy was acknowledgement that a well-trained rapidly increasing, including the use professional was needed to man- dine, hydralazine, reserpine, and of parenteral nutrition and chemo- propranolol. The most common therapy regimens, prompting the of drug therapy. Why did a change therapy for peptic ulcer disease was beginning of some specialization in in location of the pharmacist, from an antacid regimen. Psychotropics pharmacy. diazepam, tricyclic antidepressants, The first metamorphosis: Birth of
the clinical pharmacist
At some point during those early and to other caregivers had been a generation cephalosporins were just years, I realized that I was witnessing missing essential element required being marketed, and ibuprofen was a dramatic change in the pharmacy to create a relationship that was both relatively new. However, colleges of pharmacy mation that had begun slowly, ap- did begin to introduce therapeutics proximately 10 years earlier, with nurses. It was this personal contact and clinical clerkships into their the work of Whitney Award recipi- curricula. The doctor of pharmacy ent Bill Smith2 at the University of terdisciplinary team. Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
Harvey A. K. Whitney
Lecture Award
fines of the pharmacy to practice on the patient care unit. We were in the Past Recipients
The pharmacy practice model of
profession has embraced the concept of pharmaceutical care conceived by Harvey A. K. Whitney (1894–1957) received his Ph.C. degree from the University of Michigan College of Pharmacy in 1923. He was appointed to the pharmacy staff of University Hospital in Ann Arbor in 1925 and was named Chief Pharmacist there in 1927. He served in that position for almost 20 years. He is credited with establishing the first hospital pharmacy intern- ship program—now known as a residency program—at the University of Harvey A. K. Whitney was an editor, author, educator, practitioner, and hospital pharmacy leader. He was instrumental in developing a small group of hospital pharmacists into a subsection of the American Phar ma ceutical Association and finally, in 1942, into the American Society of Hospital Pharmacists. He was the first ASHP President and cofounder, in 1943, of the Bulletin of the ASHP, which in 1958 became the American Journal of Hospital Pharmacy (now the American Journal of Health-System Pharmacy). The Harvey A. K. Whitney Lecture Award was established in 1950 by the Michigan Society of Hospital Pharmacists (now the Southeastern Michigan Society of Health-System Pharmacists). Responsibility for administration of the award was accepted by ASHP in 1963; since that time, the award has been presented annually to honor outstanding contributions to the practice of hospital (now health-system) pharmacy. The Harvey A. K. Whitney Lecture Award is known as “health-system pharmacy’s highest honor.” Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
best-drug-therapy practices and medicine, to mention just a few areas Community pharmacy practice.
reporting outcomes, and are linking ing in sterile-product pharmacies cies, the preferred practice model such concepts to reimbursement. and informatics have evolved to the includes the provision of complete Pharmacy education, training, point that they might be called spe-
and certification. All pharmacy cialists in their own right.
Pharmacy technician certification available to the pharmacist. Com- pharmacy degree. Curricula include is widely available, and formal tech- periences and a full year of advanced ing in numbers. States have begun viding them with the data to better practice experience. Therapeutics to adopt laws requiring technician advise their patients and physician coursework now dominates the certification and are considering colleagues. Medication-use evalu-curriculum. In addition, wellness minimum educational require- prevention and chronic disease ments. Technicians are responsible enhanced collaboration with the pa-management are being emphasized. for most or all of the drug prepara- Our curriculum is now an integrated tion and distribution activities in that time and reimbursement allow. plan of study, providing an in-depth hospitals and community pharma- cies. Several major pharmacy chains vide advanced medication therapy tion use, from selecting drug therapy require all technicians to complete management services11,12 and give to achieving optimal effects. In 1974, ASHP-accredited technician train- pharmacy students were often told ing programs. Collaborative practice. Collab-
orative pharmacy practice models are readily accessible primary health (a form of dependent pharmacist care providers. In the Asheville prescribing) have been established Project, community pharmacists and now exist in at least 43 states.5 demonstrated significantly improved Broadly, these models have given outcomes in the management of graduate year 2 residencies, with the pharmacists the ability to initiate, patients with diabetes, reducing total second year focused on specializa- tion. Multiple research fellowships apy based on protocols developed Hospital and clinic pharmacy
are also offered. Max Ray and Donald with their physician partners. These practice. In hospitals and health
Letendre spent many years at ASHP models often include authority systems, the practice model now
envisioning and carefully guiding to order laboratory tests, conduct includes extensive use of automa-
residency training forward to this physical assessments, and change tion, robotics, smart infusion pumps,
point, and Janet Teeters continues medications within a therapeutic computerized prescriber-order-entry
to advance this work. Both ASHP class.6,7 Their development started (CPOE) systems, bar-code-assisted
and the American College of Clinical slowly but increased with dramatic medication administration, and
Pharmacy (ACCP) have called for all speed, due in part to leaders like software that can apply and retrieve
pharmacists providing direct patient Janet Carmichael, who recognized information to assist in the prescrib-
care to complete, at minimum, a the opportunity to push pharma-
Collaborative models have evolved tion systems are evolving to provide a Specialties certifies pharmacists in even further in Canada and the Unit- pharmacotherapy, nutrition support, ed Kingdom. In the Canadian prov- oncology, psychopharmacy, nuclear ince of Alberta, there are three levels tion, and apply rules-based decision-pharmacy, and, soon, ambulatory of collaborative models: adapting a making tools. Newly and soon-to-be pharmacy practice. Pharmacotherapy prescription, prescribing in an emer- specialists can also receive advanced gency, and independent prescribing a reality where all i.v. admixtures may credentials in infectious disease and based on a collaborative relation- ship.8 Two models exist in the United man manipulation.
macy specialists practicing in critical Kingdom: supplemental prescribing care, pediatrics, primary care, organ and independent prescribing across cal pharmacy services hospitalwide transplantation, pain management, all classes of drugs in the area of the in many institutions. They design drug information, and emergency pharmacist’s expertise.9,10 Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
follow patients to ensure therapeutic vision for practice model design and 1. Health care will become increasingly outcomes. They incorporate the fun- damental elements of pharmacy care, lecture.22 The second metamorphosis: The
pharmacy generalist and the
tion safety permeating every aspect pharmacy specialist
ing for individual patients, the role of observed, we have now evolved to 3. The vast majority of all pharmacist the drug information pharmacist has the point that the activities of the evolved to one of population-based person we called the clinical phar- care, including drug protocol design, macist in 1974 have become so com- drug policy design, and the effective monplace that these activities are implementation of rational drug use performed by all pharmacists. Thus, across populations of patients. Some the 1974 clinical pharmacist who 4. A trained, certified, and potentially of these pharmacists have migrated was seen as a specialist has become to the community, applying these the pharmacy generalist of today. principles to even larger populations Furthermore, we have witnessed a covered by health insurers, pharmacy second important metamorphosis benefit management companies, and of our practice model: many of 5. Increased definition and standardiza-corporations. Pharmacists are more frequently as pharmacy specialists. I wonder practicing in the ambulatory clinics if Harvey A. K. Whitney could have ness and management of chronic that so many of us have witnessed in disease into their practices, and some just 35 years? nuity of care. While the groundwork model continues to evolve? Will we sive, participation by pharmacists in greatly increased pace and volume of clinics nationwide is still very limited. Pharmacists have demonstrated us? They will not if we collectively 7. Every patient should receive a that when participating on the embrace change, question accepted health care team in hospitals, they practices, and use the data available duce adverse drug events, reduce in his 1995 Whitney Award address, patients’ length of stay, and reduce we should not be afraid to be icono- total health care costs. I refer you clasts, nor should we be afraid of to several studies by Chester Bond advocating change, especially change and Cynthia Raehl,15-20 along with that will lead to better medication a 2008 review article summarizing therapy outcomes. efit of clinical pharmacy services in Future practice model design
So what form should our new 9. In the community, most pharmacy model is now quite comprehensive, pharmacy practice models take? No evolving from the very limited one I one knows for certain, but based on observed in 1974. If you doubt this, trends and patient care needs that now exist, I would like to offer 10 10. Collaborative practice will evolve to care System in Georgia and visit the concepts we should keep in mind Department that Burnis Breland when designing and implementing directs. He described his model and these future models of care.
Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
Redesigning rather than
setting bodies are recognizing the tems and practice models, allocating Let me first address directions we importance of providing evidence- might take to create future practice based health care and are defining sion. If we do this effectively, what models in hospitals and health sys- the types of care that should be we now broadly call the monitoring tems. We know that automation will provided. For example, the Centers of drug therapy will be much better
increase at an accelerated pace along for Medicare and Medicaid Services defined and more firmly woven into
with more sophisticated robotics and (CMS) continues to add required the fabric of interdisciplinary health
clinical information systems. As these core medication measures in select care.
systems further evolve, they will make patient populations, such as those
our medication-use systems safer with cardiovascular, pulmonary, and The medication-effectiveness
and more efficient and will provide infectious diseases. We also have vari-
dashboard and future metrics
integrated information on which to ous guidelines for treating throm- boembolic disease, hypertension, sources to provide the pharmacy care There are, however, two ways to and other diseases. Unfortunately, that our patients deserve, it is critical utilize the new technology that is these guidelines are not universally that we also develop the appropriate rapidly descending on us. The first followed. Why is this? I would argue metrics and measurement tools. The is what we often do: adapt it to fit that we have reached the point in concepts of “balanced scorecards”24 our existing models of care. The medication therapy complexity that and “dashboards”25-28 might be ap-second is what we must do: change we need a designated professional, plied. I suggest that we develop a and redesign our care models to the pharmacist, to take ownership “medication-effectiveness dash-capitalize on these technological of it. Yes, the care currently provided by different indicators measuring the ef- mize our resources rather than our pharmacy generalists and special- allow technology to absorb them. ists goes far beyond these nationally use system. For example, by redesigning prac- tice models with CPOE, wireless However, our services have not been sophisticated aggregate data related systems, electronic prescribing, and well cataloged or universally offered to pharmacy care yet be presented automation, we should be able to to each patient. I am suggesting that in a simple format. I suggest that move even more pharmacists and we specifically define the medication this dashboard consist of four technicians out of pharmacies to therapy services necessary for each gauges: (1) a pharmacy personnel patient care units and clinics. In patient admitted to hospitals. This productivity index, (2) a medica-addition, new clinical information should be the first step in practice tion therapy outcomes index, (3) a systems will provide a tool to docu- For example, every patient might total medication therapy cost index. ing the pharmacy practitioner’s receive a structured pharmacist- directed medication history, followed which could be compared to other by the assessment of every medica- Specifically defining the
tion for complete appropriateness, very comprehensive picture of our components of direct pharmacy
application of all best drug therapy effectiveness. In short, the MED is a patient care services
practices and collaborative protocols, tool that presents and quantitatively As Burnis Breland22 stated in his targeting of drugs that require en- 2006 Webb lecture, “The practice hanced attention for appropriate use, outcomes. model should be specifically de- scribed, understood, visualized, and monitoring, patient education, and tivity index might include relative emphasized to pharmacy staff and so on. Furthermore, specific services value units for all important spe-others within the organization.” I would be defined for each identified cific pharmacy services designated would add that we can no longer rely high-risk and therapeutically com- on such broad terms as review, assess- plex patient type, such as oncology, defined in our new practice models. ment, and monitoring of drug thera- py. The specifics of this review should plantation patients. Based on these required direct report these services. Our existing National accrediting bodies, patient care services, teams of our personnel productivity measurement Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
if we redesign our practice models, specific patient types and might serve the pharmacist most often checking these measurement systems will need as a source of information to help or reviewing physician prescribing to be redesigned to reflect the new build this index. ASHP might engage after the fact. I believe that as we services provided. The new informa- more extensively in the development move into the future, more and more tion generated and tracked could also of these productivity and clinical da- be used to assist with scheduling and tabase systems for the MED.
to assign patient care loads to each The comprehensive,
multidisciplinary, and transferable enough pharmacists in our hospitals
pharmacotherapy plan
outcomes index, the second gauge ity and accountability for medica- of this dashboard. Each of the CMS tion therapy, the development of do so if we effectively incorporate core measures related to medication a pharmacotherapy plan29 that is automation, clinical information sys-therapy might be included in this comprehensive, multidisciplinary, tems, and a highly trained technician index. In addition, other measures, accessible, and transferable is a must. work force that assumes additional such as the percentage of patients The plan should contain all desired and more complex activities. It will on defined antimicrobial regimens outcomes, therapeutic goals and require extensive practice model matching culture and sensitivity endpoints, timelines, and monitor- ing criteria. I am suggesting that this and documentation of the effect of porting effective pain management formal pharmacotherapy plan be a our services. Care costs will become scores, and percentage of patients required module in every new clini- cal information system. Too often, provide these services will follow. globin levels, might be included and pharmacotherapy plans are hidden, Furthermore, when we have designed weighted accordingly. This gauge not accessible to those other than the a more standardized approach, we would give us a relative quality in- dex to complement our productivity ditional medication profile format, of pharmacists by both our colleague index. with additional information spread practitioners and, most importantly, The third dashboard gauge would throughout the medical record. New our patients. provide a medication safety index. clinical information systems that Components of this index might in- can create and present complex care The next metamorphosis:
clude the number of reported adverse plans provide an excellent opportu- Ambulatory care pharmacy
events causing significant patient nity to facilitate the development of harm (with a goal of zero), number a new pharmacotherapy plan. The future pharmacy practice models in of adverse drug events prevented pharmacist, in partnership with the ambulatory care. For some time now, or intercepted, presence or absence health care team, should have the we have seen an increasing number of important safety systems such as responsibility and accountability for of pharmacists and specialists prac-bar coding and CPOE, percentage of the development and implementa- we believe should be standardized in macotherapy plans should lead to and skills that they had provided to all hospitals. a further evolution in collaborative their inpatients. They have extended Finally, the forth gauge on the drug therapy, including additional the management of acute medication MED would be a total medication pharmacist prescribing. I believe therapy to the management and pre-therapy cost index. It would take into that the growing trend of employ- account not only drug costs but the ing hospitalists to manage patient the literature documents the value total costs for treatment of types of care will further assist in this, as the of pharmacists,21,30-36 only a relatively patients heavily dependent on effec- hospitalist and the pharmacist, both few patients are seen by a pharmacist tive medication therapy. This would permanently assigned to the patient during their clinic visit. account for length of stay, adverse care unit, will know each other’s drug effects, and therapeutic failures. capabilities well and rely heavily on phosis in pharmacy will be seen in The University HealthSystem Con- each other. While this often occurs ambulatory care. The community today, medication-use processes still pharmacists of today will become tabase of cost information for many remain distinctly segmented, with the ambulatory care pharmacists of Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
tomorrow. Their practice sites will be cific diseases, drug-related problems, reimbursement mechanisms pro-
in all types of clinics—large, small, polypharmacy, preventable adverse vided by health care payers.
hospital based, health-system based, drug events, and previous subopti-
and independent. In addition, large mal outcomes of medication therapy. Further evolution in pharmacy
ambulatory care pharmacy centers A study of patient flow and processes education, training, and
providing most of drug product used in clinics could then assist in de-
dispensing, distribution, and other termining when during the patient centralized functions will become clinic visit the pharmacist interven- tion should occur and with which offered in 1974 when I was a student dressed these thoughts in his 2005 patients. article entitled, “Unresolved Issues in The future pharmacy clinic prac-
tice model. Consider an ambula-
Facilitating ambulatory care tory care model where one of the from now? I cannot fully answer that
pharmacy practice model change. first providers to see a patient in a question, but I do know that we will
We have an important opportunity clinic is the pharmacist to obtain or need to rapidly incorporate addition-
to facilitate this transformation by oversee a comprehensive medication al coursework in physical assessment,
redesigning hospital-based clinic history and assess the patient’s past informatics, and molecular and ge-
practice models. E-prescribing, inter-
tems, automated prescription filling, plete electronic health care record Harold Godwin46 was prophetically and enhanced use of technicians will and communicate with the patient’s aware of this when he stated the fol-assist us in moving more pharmacists acute care pharmacist and ambu- from hospital outpatient pharmacies latory care pharmacy center. The “To meet the challenges of being and community pharmacies into patient’s detailed pharmacotherapy responsible for optimal therapy out-clinics. As Rita Shane38 stated so well plan would be prepared or updated comes, our practitioners are going to in her 1995 Webb lecture, “If we are and be electronically available for use need more training and confidence ‘built to last,’ we will move outside by all practitioners throughout the in patient assessment techniques.” To the walls within which we have cre- visit. This pharmacist might also see achieve these additions to the cur- the patient at the end of the visit to ricula, some additional basic science In the late 1980s, Koecheler et determine if drug therapy should be courses might need to be moved al.39 developed and tested indicators prescribed or changed in conjunc- that could target ambulatory care tion with the team, along with setting gram to the preprofessional years, patients who might benefit from a monitoring parameters. pharmacist’s intervention in a clinic, Select patients would also receive a four-year degree before entering such as numbers and types of drugs communication from the pharmacist pharmacy school. Several pharmacy prescribed, therapy changes, disease between clinic visits to monitor and schools already require a bachelor’s states, and compliance history. These change therapy as necessary. This degree for entrance. Furthermore, indicators were applied in a study by communication might come from the first two years of professional Lobas et al.40 and suggested that the the clinic-based pharmacist or the study should offer at least some com-provision of comprehensive pharma- ambulatory care pharmacy center bined coursework, particularly with ceutical care in an ambulatory care pharmacist, as elucidated in the pa- clinic can reduce medication costs tient’s pharmacotherapy plan. Thus, process of seeding interdisciplinary and improve quality of care. Ellis et adherence to medication therapy, care and acquainting each other with al.41,42 later used these indicators in detection of adverse drug events, and how the two professions are interde-the IMPROVE study and found that earlier determination of therapeutic pendent and work together. Finally, pharmacists can identify and resolve success or failure would be facilitat- drug-related problems and improve ed.43-45 The pharmacists in the clinic ciplinary advanced practice experi-care for ambulatory patients with and in the ambulatory care center ences in the third and fourth years of various chronic diseases.
pharmacy would work as a team and the professional experience.
In designing future pharmacy jointly define their patient care re- clinic practice models, we should sponsibilities, facilitated by the com- make use of the data available. New mon electronic clinical information for credentialing and licensure of clinical information systems may system. Practice models will certainly pharmacists providing advanced help us identify patients with spe- be influenced by business plans and practice. In its 2006 vision paper, Am J Health-Syst Pharm—Vol 66 Aug 15, 2009 Harvey a. K. WHitney Lecture Pharmacy practice model
ACCP stated that in 20–30 years, 35 years. This will require significant career. I owe them a great debt of most clinical practitioners will be practice model redesign in hospi- tals and in the community. It will Pierpaoli, Harold Godwin, Sara require a heavier dependence on White, Don Letendre, Bruce Vinson, Conclusion
an even more highly educated and and Toby Clark. Thank you all. tion, I read through lectures of my require that our practice models be References
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Am J Health-Syst Pharm—Vol 66 Aug 15, 2009


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Arthur L. Costa, Ed. D. Bena Kallick, Ph.D. Por definición, un problema es cualquier estímulo, pregunta, tarea, fenómeno o discrepancia, la explicación que no sabemos inmediatamente. Por lo tanto, el interés está en centrar la atención del rendimiento de los estudiantes en virtud de esas condiciones difíciles que exigen razonamiento estratégico, perceptividad, perseverancia,

Microsoft word - mrsa policy.doc

MERCY HOSPITAL DUNEDIN INFECTION CONTROL MANUAL MRSA Policy Page 1 of 17 Key Words: Methicillin Resistant Staphylococcus aureus , MRSA Policy Applies to: All staff employed by Mercy Hospital. Credentialed Specialists, Allied Health Professionals, patients and visitors will be supported to meet policy requirements. Related Standards: • Infection and Prevention a

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