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Supplemental Material for Integration and impact of pharmacists in general practice internationally: A rapid review by Georgios Dimitrios Karampatakis, Nilesh Patel, Graham Stretch and Kath Ryan in Journal of Health Services Research & Policy

ntroduction: Health system leaders have a vital role to play in ensuring the delivery of high-quality care. Improving the quality of healthcare, particularly in low-income countries often focuses on the performance of healthcare providers and the availability, acceptability, and uptake of services. The role that health service leaders play in facilitating effective care has received less attention in the literature. This study explored the perspectives of Afghan maternity care providers, managers and other stakeholders on leadership and the provision of quality maternity care.\ud \ud Methods: This ethnographic study used semi-structured interviews, participant observation, and background interviews for data collection. The research setting was a Kabul tertiary maternity hospital. Participants included doctors, midwives and care assistants who were employed in the hospital (n=23). Stakeholders from the health system, government, community and non-governmental organizations provided background interviews (n=41). A thematic framework analysis was conducted across all the data sets and different participants to maintain the context and perspectives of individual groups and identify themes.\ud \ud Results: The results of this study involves 1. Healthcare providers who described their managers as both autocratic and weak. They explained that their managers failed to enforce standards or listen to their concerns. 2. Managers who felt powerless to improve care because the government did not support their initiatives to reform the working environment or discipline staff members who were flouting the rules.\ud \ud 3. Background interviewees who concurred that hidden relationships influenced and undermined the health system at all levels.\ud \ud Conclusion: An unofficial system of connections with powerful people gave some staff privileges and power beyond their roles and undermined the power of managers who were responsible for standards of care. Strong, unwavering political will and tenacious leadership will be needed to address this. We suggest that initiatives to improve the quality of care in other low- and middle income countries (LMICs) look beyond individual staff and official systems to determine who holds the power and how that power is used

Background: In England, there is an ongoing national pilot to expand pharmacists’ presence in general practice. Evaluation of the pilot includes numerical and survey-based Key Performance Indicators (KPIs) and requires pharmacists to electronically record their activities, possibly by using activity codes. At the time of the study (2016), no national evaluation of pharmacists’ impact in this environment had been formally announced. The aim of this qualitative study was to identify problems that English pharmacists face when\ud measuring and recording their impact in general practice.\ud Methods: All pharmacists, general practitioners (GPs) and practice managers working\ud across two West London pilot sites were invited, via e-mail, to participate in a focus group study. Appropriately trained facilitators conducted two audio-recorded, semi-structured\ud focus groups, each lasting approximately one hour, to explore experiences and\ud perceptions associated with the KPIs. Audio-recordings were transcribed verbatim and\ud the data analysed thematically. Results: In total, 13 pharmacists, one GP and one practice manager took part in the study. Four major themes were discerned: inappropriateness of the numerical national KPIs (“whether or not we actually have positive impact on KPIs is beyond our control”); depth and breadth of pharmacists’ activity (“we see a huge plethora of different patients and go through this holistic approach - everything is looked at”); awareness of practice based pharmacists’ roles (“I think the really important [thing] is that everyone knows what pharmacists in general practice are doing”); and central evaluation versus local initiatives (“the KPIs will be measured by National Health Service England regardless of what we think” versus “what I think is more pertinent, are there some local things we’re going to measure?”). Conclusions: Measures that will effectively capture pharmacists’ impact in general practice should be developed, along with a set of codes reflecting the whole spectrum of pharmacists’ activities. Our study also points out the significance of a transparent, robust national evaluation, including exploring the needs/expectations of practice staff and patients regarding pharmacists’ presence in general practice.

Additional file 1:. Interview schedule. This additional file consists of a table that presents the interview schedule developed and used in this study.

Objective: Variable rate intravenous insulin infusion (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Health Care, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIIIs are perceived to be used by healthcare practitioners, focusing on one aspect of RHC: understanding how work is assumed to be done by using a method called Hierarchical Task Analysis (HTA).\ud Design: A qualitative study using document analysis and focus groups. \ud Setting: A Vascular Surgery Unit in a UK tertiary, acute National Health Service (NHS) teaching hospital.\ud Participants: Various stakeholders/users in different professional roles involved in the process of using VRIIIs.\ud Results: The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations e.g. proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care.\ud Conclusion: Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIIIs are used and to understand how adaptations are made in relation to the use of VRIII.

Additional file 1: Mixed Methods Appraisal Tool (MMAT) checklist items [20].

Additional file 2: Quality assessment of included studies.