1965–1972: The Ninth Floor Pharmacy Project
An expanded role for pharmacists begins
In early fall 1965, leaders at the School of Pharmacy (Troy Daniels, Jere Goyan, Sidney Riegelman, Donald Brodie, and Donald Sorby) began exploring the creation of a real-world laboratory at UCSF Medical Center to define and study an expanded role for pharmacists, beyond product experts, consistent with the School’s educational goals.
They secured cooperation from UCSF Medical Center Chief Executive Officer Robert Derzon, Director of Nursing Irma Nickerson, Chancellor John de C.M. Saunders, Chair of Surgery J. Englebert Dunphy, Director of Pharmaceutical Services Donald Brodie, and Chief Pharmacist Eric Owyang.
Fortuitously, UCSF nursing services was conducting an experiment to improve the quality and efficiency of nursing care and to address nurses’ frustration with drug-order turnaround time. The nursing team eagerly endorsed the idea of a decentralized pharmacy, and the chief of surgery volunteered the surgical floor for the first satellite pharmacy.
The Ninth-Floor Pharmacy Project rolled out on September 7, 1966, after months of planning under the direction of William Smith who had been in a two-year residency program overseen by Brodie and Owyang.
The service commenced with the following goals:
- Develop a hospital-floor-based pharmaceutical service that will provide maximum safe drug use in patients.
- Charge the pharmacist with responsibility for all phases of drug distribution, except the administration of medication to the patient.
- Provide an unbiased and easily available source of reliable drug information (the pharmacist) and disseminate information according to the needs of professional personnel.
- Provide clinical experience for interns, residents, and other qualified pharmacy students in the hospital pharmacy.
- Design and conduct studies in cooperation with physicians and nurses to evaluate institutional pharmacy services within the framework of a team approach to patient care.
In addition to Smith, Robert Miller, Joseph Hirschmann, Richard de Leon, and Donald Holsten were the initial crew of pharmacists on the project. Dennis Mackewicz, Toby Herfindal, and Robert Levin later joined them. Staff pharmacists from the medical center also participated.
Seven months after starting the service, Smith submitted the following report:
The practice of pharmacy on the hospital floor appears to be a logical and direct method to help solve the various problems associated with modern complex drug therapy and drug distribution. Several members of the surgical and nursing personnel have expressed their acceptance of the pharmacist on the patient care team because he adds to the overall effort of providing care. The pharmacists believe that the type of service developed is the only kind of pharmaceutical services that should exist in the hospital.
In fall 1967 when Smith left to become director of pharmacy at Long Beach Memorial Hospital, Miller was appointed director. Initially the pharmacists were consumed by the requirements of the unit-dose drug distribution system. They knew that a critical measure of success was reducing medication turnaround time.
As the kinks were worked out of the distribution system, pharmacists were increasingly able to participate in more direct clinical activities such as rounding and participating in codes. By 1968, the pharmacists had developed a work pattern that included supervising technicians who filled unit-dose orders, preparing IV additives, participating in teaching and work rounds, responding to Code Blue calls, replying to drug information requests from house staff and attending physicians, providing in-service teaching to nursing staff, and teaching pharmacy students and residents.
A pharmacy satellite was established in the pediatric clinic in the outpatient clinic building in 1968.
1968: Drug Information Service increases access and quality of drug information
Many of the questions generated by medical staff required extensive literature searches. This generally necessitated a trip to the medical library located on the first floor and basement of the medical center. As the volume, scope, depth, and occasionally urgency of requests increased, time away from the floor became an issue. The service was 24/7 and staffed with only one pharmacist at a time. Consequently in 1968 the team established the Drug Information Service (later known as the Drug Information Analysis Service, aka DIAS). Located in the medical library, it was initially staffed on a rotating basis by the ninth-floor pharmacists then soon staffed full-time by Hirschmann and pharmacy residents. Over time, the scope of services expanded to include responding to information requests from any physician or pharmacist in the community and poison control questions from physicians at San Francisco General Hospital and other emergency departments. The service was responsible for providing critical evaluations of drugs considered for inclusion in the hospital formulary as part of the UCSF Hospital Pharmacy and Therapeutics Committee.
1968: Ninth-floor Project receives wider attention
The Ninth-floor Project began to achieve a degree of campus exposure. In fall 1968, the UCSF Health Sciences Television Network devoted a segment of This Moment in Medicine to an emerging new specialist on the health care team—the clinical pharmacist. Hirschmann, Holsten, and Miller joined Don Carlos Hines, MD, a pharmacologist from the School of Medicine, in examining this new role. They used examples of therapeutic issues identified by ninth-floor practitioners to illustrate the clinical pharmacist impact on patient care. Using their experiences, they attempted to move clinical pharmacy from concept to reality.
1969–1970: Curriculum radically revised
In April 1969, the School held a two-day conference called Clinical Pharmacy and the Professional Pharmacy Curriculum. The Ninth-floor Project was the centerpiece of the Schoolwide discussion. Based on the experience and observations of the pharmacists involved, the message to the faculty by the ninth-floor pharmacists was that the existing curriculum did not adequately prepare students to function effectively in an expanded role in health care. The PharmD curriculum that was designed to produce the “drug expert” was found wanting.
It was a difficult message to deliver and perhaps even more difficult to receive. Nevertheless, the faculty—representing all disciplines—eventually supported the initiation of an intensive evaluation of the curriculum. Working committees were appointed shortly thereafter, and the process of radical revision began in earnest. In August 1970, the new curriculum was presented and approved in principle by the faculty after a remarkably brief period of discussion. Many courses, especially those with laboratories, vanished or were condensed; new courses, primarily clinical and biological, were introduced; and the fourth year was devoted entirely to clerkships. During a two-year implementation period, the formal curriculum underwent radical change.
In September 1970, the School and the National Center for Health Services Research convened a national invitational symposium called Challenge of Pharmacy in the 70s. The invitees included federal bureaucrats, elected officials, association executives, physicians, nurses, pharmacists, and pharmacy school deans and faculty members. Speakers included UCSF administrators, nurses, physicians, and pharmacists who described their experiences with the clinical pharmacy program. In preparation for the symposium, the School produced a two-hour video, An Orientation to Clinical Pharmacy, showing pharmacists and pharmacy students rounding, interviewing patients, and working in the DIAS and in several outpatient clinics. Produced and directed by Robert Day and narrated by Herfindal, the video reinforced the observations of the speakers in a way unique for its time. Looking back, Day observed, “It was radical even then, in the early 1970s.”
1972: Clinical pharmacy practice widens at UCSF
By 1972, clinical pharmacy services had expanded to four floors of Moffitt Hospital and six floors in the newly constructed Ambulatory Care Center. The unit-dose system was centralized, but the clinical pharmacists remained on the floors of the hospital. Although they were not involved in order fulfillment, they served as liaisons with the central pharmacy. This arrangement allowed clinical faculty to increase contacts with pharmacy students and devote more time to classroom teaching and creative activities. The clinical pharmacy faculty was responsible for teaching about 30 percent of the units required for graduation. The full-time clinical faculty expanded significantly, including Gary McCart, Donald Kishi, Mary Anne Koda-Kimble, Theodore Tong, Steven Kayser, Michael Winter, Rosalind Sato, Sam Shimomura, Thomas Dunphy, David Adler, Dennis Andrews, Betty Dong, Michael Riddiough, and Brian Katcher.
Next: 1973–1994: Herfindal