Abstract
Objective:
Tech-check-tech (TCT) is a practice model in which pharmacy technicians with advanced training can perform final verification of prescriptions that have been previously reviewed for appropriateness by a pharmacist. Few states have adopted TCT in part because of the common view that this model is controversial among members of the profession. This article aims to summarize the existing research on pharmacist and technician perceptions of community pharmacy–based TCT.
Data Sources:
A literature review was conducted using MEDLINE (January 1990 to August 2016) and Google Scholar (January 1990 to August 2016) using the terms “tech* and check,” “tech-check-tech,” “checking technician,” and “accuracy checking tech*.”
Data Synthesis:
Of the 7 studies identified we found general agreement among both pharmacists and technicians that TCT in community pharmacy settings can be safely performed. This agreement persisted in studies of theoretical TCT models and in studies assessing participants in actual community-based TCT models. Pharmacists who had previously worked with a checking technician were generally more favorable toward TCT.
Conclusion:
Both pharmacists and technicians in community pharmacy settings generally perceived TCT to be safe, in both theoretical surveys and in surveys following actual TCT demonstration projects. These perceptions of safety align well with the actual outcomes achieved from community pharmacy TCT studies.
Background
Tech-check-tech (TCT) is a practice model in which pharmacy technicians with advanced training can perform final verification of prescriptions that have been previously reviewed for appropriateness by a pharmacist. In institutional settings, TCT has been demonstrated to maintain or improve the accuracy of the dispensing process. 1,2 In a review of nearly 30 years of institutional TCT studies, technicians demonstrated a dispensing accuracy rate of 99.6%, compared to 99.3% for pharmacists (no statistical difference). 2 In addition, institutional TCT studies freed pharmacists for clinical services, ranging from 10 hours per month to 1 hour per day. 2
Community pharmacy–based TCT has recently gained momentum. We reviewed 4 studies published between 2002 and 2016 that analyzed TCT in community pharmacy practice settings. 3 In all studies, technicians performed as accurately as pharmacists in the dispensing process. 4 –8 In 1 study, technicians statistically outperformed pharmacists in dispensing accuracy (99.74% vs 99.95%, respectively, P < .05). 8 Three of these studies explored the impact on gains in pharmacist time from a TCT model. Each found that even after a short time period following implementation, the percentage of pharmacist time devoted to direct patient care had increased between 9% and 19%. 3 In 1 instance, the investigators reported that TCT could save pharmacists 11 150 minutes—or 23 days—per year. 8 Thus, the benefits of TCT appear to persist across practice settings.
Despite the patient care benefits that stem from TCT, only North Dakota currently allows TCT outright in community pharmacy practice settings. As of spring 2016, several states are actively exploring TCT in community practice settings through rule changes or through waivers, including Arizona, Idaho, Iowa, New Hampshire, South Dakota, and Wisconsin. 5,8 –11 Idaho’s law change, which would enable TCT in any practice setting, is set to take effect in March 2017. 11 One of the potential hang-ups in expanding TCT beyond institutional settings is the belief that this practice model may be perceived negatively by pharmacists. For example, in opposing commentaries on TCT, some pharmacists have focused on the potential negative impact TCT may have on pharmacist jobs, whereas others focused on the impact TCT may have on increasing the clinical role of the pharmacist. 12 –14
Given the emotions that typically surround an issue like TCT, it is often the case that regulatory bodies are reticent to take on this issue. To explore the extent to which the profession views TCT as a positive or negative with respect to patient safety, this article aims to summarize the existing research on the perceptions of community pharmacy TCT practice models from the perspective of both pharmacists and technicians. We reviewed both surveys of a theoretical TCT model and feedback from participants in an actual TCT program with an emphasis on the perceived safety of such a model.
Methods
We searched MEDLINE (January 1990 to August 2016) and Google Scholar (January 1990 to August 2016) using the terms “tech* and check,” “tech-check-tech,” “checking technician,” and “accuracy checking tech*.” The bibliographies of all identified articles were examined to identify additional relevant literature. Studies were included for further analyses if they either tested perceptions on a theoretical TCT model in community pharmacy settings or included feedback from participants in an existing TCT model that was conducted in a community pharmacy practice setting. We defined community pharmacy as inclusive of chain, independent, mass merchant, and supermarket pharmacy settings. Studies were excluded if they were not in the English language or if the TCT practice model was conducted in an institutional, long-term care, or other noncommunity setting.
Results
The search strategy identified 7 studies assessing pharmacist and technician perceptions on TCT models in community pharmacy practice settings. 6,7,15 –19 Five of the studies tested the perceptions of pharmacists and technicians on a theoretical TCT model; the remaining 2 studies captured feedback from participants in an actual TCT practice model.
Studies on Perceptions of Theoretical Community Pharmacy–Based TCT Models
The first 2 surveys identified during the literature search were conducted by Napier et al and were based on the same survey sample but published separately. 15,16 The authors aimed to compare the perceptions of competency, confidence, and comfort of pharmacists and technicians with technicians servings as “checking technicians” (CTs) in order to assess the viability of this model for New Zealand. The investigators sent surveys to all individual community and hospital pharmacists (n = 2095) in New Zealand and separately to technicians by mailing it to all pharmacies in the country (n = 858). Surveys asked respondents questions using a 5-point Likert scale, with 1 indicating “strong disagreement” and 5 indicating “strong agreement.” Responses were received from 736 pharmacists (36% response rate) and 485 technicians (unknown response rate), the majority of which were from pharmacists and technicians in community settings (80% and 79%, respectively). 15,16
Across all practice settings, 89% of technicians and 73% of pharmacists agreed that some technicians could competently act as a CT. 16 With respect to community pharmacy, both technicians and pharmacists were in agreement that technicians are capable of accurately checking prescriptions (4.4 vs 3.9, respectively), that they would be comfortable with a technician performing this task at their current level of training (3.9 vs 2.5), that they would be comfortable with a technician performing this task after extra training (4.6 vs 3.9), and that a technician would be competent with this task after extra training (4.5 vs 3.9). Across all practice settings, 82% of technicians stated they would be prepared to take on the additional responsibilities, with a corresponding 83% interested in additional educational training. Pharmacists who had previously worked with a CT were more favorable on all survey questions relative to pharmacists who had not previously worked with a CT (P < .02). 16
Napier et al also reported on common themes from open-ended feedback that pharmacists provided with the survey. 15 Separate themes were not reported from community pharmacists versus hospital pharmacists, but 80% of respondents were from community pharmacy settings, and thus the reported themes are likely to be reflective of the community sector. First, pharmacists generally reported that a CT model could lead to improvements in clinical outcomes due to more pharmacist time devoted to patient care. Second, there were mixed open comments on the impact TCT could have on dispensing errors, but fewer than 15% of pharmacists surveyed felt there would be a negative impact on public safety. Third, pharmacists reported a need for their pharmacies to adopt strong policies and procedures for TCT programs in order to minimize potential safety risks. 15
The next 3 studies identified during the literature search were conducted by Bradley et al and were based on the same survey sample (or were used to inform the survey design). 17 –19 The authors randomly surveyed registered pharmacists (n = 1500) and pharmacy technicians (n = 1500) based in England. 19 Surveys were sent with instructions for participants to respond if employed as staff of a community or hospital pharmacy. The survey explored pharmacist and pharmacy technician perceptions of how safe it would be to allow pharmacy technicians to undertake 22 different activities in community pharmacy without pharmacist oversight—one of which related directly to TCT: “accuracy checking.” The first survey question asked the respondents if pharmacy technicians could competently and safely perform each activity without the supervision of a pharmacist. The second question asked respondents about the perceived risk to patient safety of pharmacy technicians performing each activity without the supervision of a pharmacist. 17
Responses were received from 642 pharmacists (42.8% response rate) and 854 technicians (56.9% response rate). 17 Of note, 163 of the technician respondents identified themselves as an accuracy CT. With respect to whether the respondent agreed the activities could be performed safely when a pharmacist is not present, the investigators found that community technicians were much more likely than community pharmacists to believe accuracy checking could be safely performed (72.2% vs 43.2%, P < .001). Similarly, with respect to the perceived risk level, community technicians were much more likely than community pharmacists to report accuracy checking as having “no or low risk” (62.9% vs 31.8%, P < .001). Community pharmacists generally had a lower comfort level with accuracy checking in the absence of a pharmacist than hospital pharmacists. For instance, 31.8% of community pharmacists listed accuracy checking as having “no or low risk” compared to 55.7% of hospital pharmacists (P < .001). Conversely, community technicians and hospital technicians were equally likely to report accuracy checking as having “no or low risk” (62.9% vs 65.7%, P = .437). Pharmacists who reported working with accuracy CTs had greater confidence in the ability of technicians to perform accuracy checking relative to pharmacists who had not worked previously with an accuracy CT (2.29 vs 2.82, P < .001). Similarly, community technicians who currently practice as accuracy CTs reported much stronger agreement that accuracy checking could be safely performed relative to technicians who do not currently practice as an accuracy checker (P < .001). 17
Studies on Perceptions From Actual Community Pharmacy–Based TCT Models
A demonstration project hosted by the Pharmaceutical Society of New Zealand was conducted in 7 community pharmacies and 4 hospital pharmacies. 7 The goal of the demonstration project was to assess the feasibility and the impact of utilizing pharmacy accuracy checking technicians (PACTs). In conjunction with this, investigators sent online surveys to participants and also conducted 10 phone interviews with technicians and supervising pharmacists who participated in the project. The online survey was completed by 12 of 15 participating technicians and 9 of 12 pharmacists, the majority of whom were in community practice settings. The report notes that full survey and interview results will be published elsewhere, and they were not identified as available at the time of this review. However, a few findings were documented in the report.
All pharmacists responding to the online survey indicated they felt “very confident” that the CTs had the skills and knowledge needed to perform the new checking role after the training. Eleven (92%) of the technicians rated themselves as “very confident” in this regard, with the remaining technician choosing between a 3.5 and a 4 on a 5-point Likert scale (1 = not at all confident; 5 = very confident). The investigators did not identify if the technician who did not respond as “very confident” practiced in a community or hospital setting. 7
Supervising pharmacists and pharmacy technicians both indicated a positive experience with the implementation of the PACT program in the telephone surveys. 7 One pharmacist reported: “Everyone was on board and wanted this program to be a success. Our PACT was an outstanding candidate and made the environment of the pharmacy better.” The majority of respondents communicated improvement in workflow, with 1 pharmacist noting, “it will be a bit of work to start with, but in the end it is really good for the whole team.” In addition, both pharmacists and technicians relayed their increased job satisfaction that stemmed from the new model. Finally, feedback indicated that the project had the potential to be rolled out nationally. The investigators found that “all those who participated in the project said the potential impacts of a national roll out…would be very positive for technicians, pharmacists, pharmacies, and patients.” 7
The last study identified was conducted by Andreski and colleagues. 6 The Iowa state Board of Pharmacy approved a community pharmacy–based TCT pilot program which included participation from 7 different independent pharmacies. In conjunction with the demonstration project, a survey on various components of workplace satisfaction was conducted. A baseline survey was completed by 20 technicians and 17 pharmacists at participating stores; a follow-up survey was completed by 13 technicians and 10 pharmacists at participating stores. There was no reported statistical difference (P > .05) in any measure of workplace satisfaction after 18 months, including job satisfaction, role overload, role ambiguity, role conflict, stress, or profession choice. 6
Discussion
Of the studies identified by our review, we found general agreement among both pharmacists and technicians that TCT in community pharmacy settings can be safely performed. This agreement persisted in studies of theoretical TCT models and in studies assessing participants in actual community-based TCT models.
In the survey by Bradley et al, community pharmacists were much less likely than hospital pharmacists or community technicians to view TCT as safe. 17 Pharmacists who previously worked with an accuracy CT, however, were much more likely to view accuracy checking as safe. This is likely not surprising and suggests that pharmacists gain comfort with TCT when they actively participate in such a model. Further, the Bradley survey asked respondents their comfort with this model when “a pharmacist would not be present.” All existing models of TCT that have been published have had a pharmacist present to perform such activities as drug utilization review on new and refilled prescriptions. 1 –3 We are not aware of any TCT models that occur in the absence of a pharmacist. It is possible that perceptions of safety would have been higher if the investigators surveyed the delegation of accuracy checking as being performed under a pharmacist’s supervision as is usually the case in existing TCT practice models.
Due to the wording in the survey by Bradley et al, we believe that the survey results by Napier et al likely are closer to reflecting the true pulse of the profession. 15,16 Napier and colleagues showed that community technicians and pharmacists were in agreement that technicians are capable of accurately checking prescriptions. Fewer than 15% of pharmacists felt that TCT could be unsafe. 15 The perception of safety demonstrated in the published research aligns well with the safety demonstrated in 4 recent studies on community pharmacy–based TCT. 3 These studies—which date back at least 14 years—showed technicians perform at least as accurately as pharmacists in the dispensing of medications in community settings. 3
Napier et al also found that at current levels of training, community technicians believed they could comfortably perform this task, whereas pharmacists were neutral at current levels of training. 15,16 Pharmacist comfort with TCT grew as the surveyors assessed technicians performing additional training prior to engaging in this activity. In considering how to structure TCT regulations, one question regulatory bodies are often confronted with is what training requirements to set for a technician to qualify for TCT. Given the results of the study by Napier et al, regulators may increase acceptance from pharmacists by requiring advanced training requirements for community technicians to participate in TCT. We previously reported that existing TCT programs usually require a mix of baseline experience as a technician (eg, 2000 hours of experience), with added didactic and experiential training on medication error identification and resolution, as well as a validation period in which a technician demonstrates competency in checking a certain range of medications. 3
Similar to the study by Bradley et al, pharmacists surveyed by Napier who had previously worked with a CT were more favorable toward TCT on all survey questions (P < .02). 16 This finding, along with the positive feedback from the pharmacists in the New Zealand demonstration project speak well for how participants in actual TCT programs feel about their results. Although the Iowa demonstration project did not lead to any significant differences in job satisfaction, the study did maintain safety in the dispensing process while augmenting pharmacist time for patient care activities by 19.18%. 6
Overall, we presume regulatory bodies will be primarily interested in the evidence of community-based TCT as it relates to the safety of the dispensing process and its impact on pharmacist time for patient care. Regulatory bodies are typically focused on the public interest, not public opinion, though it is likely of great comfort to decision-makers that the majority of the members of the profession seem to perceive TCT as safe in the reviewed opinion surveys. Based on our review of the evidence, we would characterize significant concerns regarding community-based TCT among members of the profession as the minority opinion.
Conclusion
In the 7 studies reviewed, both pharmacists and technicians in community pharmacy settings generally perceived TCT to be safe, and this perception existed in both theoretical surveys and in surveys following actual TCT demonstration projects. These perceptions of safety align well with the actual outcomes achieved from community pharmacy TCT studies over 14 years. These findings may provide assurance to regulatory bodies that significant concerns over the safety of such models are among the minority of members of the profession.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.