2019 Pharmacy Educations3.proce.com/res/pdf/CHS2019Oct16Handout.pdfThe Business of Pharmacy CHS...

The Business of PharmacyCHS Pharmacy Education Series

ProCE, Inc.www.ProCE.com 1

2019 Pharmacy Education Series

October 16, 2019The Business of Pharmacy

Faculty Speakers:Ernest R. Anderson, Jr. RPh, MS, FASHP, FMSHPKara White Scalzo, PharmD, BCPS

Submission of an online post‐test and evaluation is the only way to obtain CE credit for this webinar

Go to www.ProCE.com/CHSRx

Print your CE statement of completion online

– Credit for live or enduring (not both)

Deadline: November 15, 2019

Pharmacists and Pharmacy Technicians: CE credit uploaded to CPE Monitor

– User must complete the “claim credit” step

Online Evaluation, Self-Assessmentand CE Credit

Attendance Code

Code will be provided at the end of today’s activity 2



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2019 Pharmacy Education Series

It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Mr. Anderson is an advisor/consultant for ConsortiEX, Continuus Pharmaceuticals, MedShorts, New England Life Care, and Trellis Rx. Dr. Scalzo does not have any relevant commercial or financial relationships to disclose.

Disclosure: The information contained in the presentation is for Community Health System employees and hospital affiliates and is not for external distribution and/or use. The presentation may contain information that is proprietary, confidential, or legally privileged or protected. It is intended only for the use of Community Health System employees and hospital affiliates. Do not deliver, distribute or copy the presentation and do not disclose its contents or take any action in reliance on the information it contains outside of Community Health Systems and hospital affiliates.

Please note: The opinions expressed in this activity should not be construed as those of the CME/CE provider. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.

October 16, 2019The Business of Pharmacy

5

CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist and Pharmacy Technician CE)This CE activity is jointly provided by ProCE, Inc. and CHSPSC, LLC. ProCE is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number 0221‐9999‐19‐507‐L04‐P/T has been assigned to this knowledge‐based live CE activity (initial release date 10‐16‐19). This CE activity is approved for 2.0 contact hours (0.2 CEU) in states that recognize ACPE providers. This CE activity is provided at no cost to participants. Successful completion of the online post‐test and evaluation at www.ProCE.com/CHSRx is required to receive CE credit. CE credit will be uploaded to NABP/CPE Monitor. No partial credit will be given.

Funding:This activity is self‐funded through CHSPSC.

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7

The Business of PharmacyErnest R. Anderson Jr. RPh. MS. FASHP, FMSHPErnest R. Anderson, Jr. Consulting Inc.

8

What Does It Take To Successfully Lead A Health System Pharmacy?

?

?

?

?

?

?

?

What spheres of accountability haveproven to be essential for success?

Leadership



9

The Proven Leadership Model

Each must be fully addressed with a genuine sense of urgency by a newAnd innovative “culture of leadership”!

LEADERSHIP?

??

?

?

? ?

Spheres?

Accountability?

10

The Premise

To be consistently successful there are seven spheres of accountability that must be recognized, mastered, and integrated together through an effective leadership strategy

Failure to recognize and/or lead any one or more of these spheres inevitably results in partial success at best & often serious consequences…



11

The Premise…

Effective leadership in each sphere is best achieved through an innovative blend of positional leaders (Big L) with very nontraditional pharmacists (little l) willing and capable of practicing strong situational leadership…. we might call …….a new culture of leadership!

12

Seeing the Whole PictureThinking at different levels

Self Based on integrity and truth

DepartmentService to individuals

Outside your departmentService to other departments, patients, physicians

Outside your hospital or pharmacyService to your profession and professional organization

The National levelGovernmental programs – CMS, FDA, NPSF

The global levelNationalized health insurance

Alignment of ContextKnow the impactUnderstand the incentives



13

How is a Pharmacy Administrator to Think? Think at different levels

Follow the moneyReimbursement

Risk contract incentives

Fee for service

Impact on pharmacy

Pharmacy expenses are primarily drugs not peoplePharmacy budget as a percentage of hospital is increasingUnderstand the perspective of all leaders (WIIFM)

The system level and the local levelBe the guide to make others the hero

How can I make you successful

14

A Proven Leadership Model

LEADERSHIP

Rx Corporate Compliance

IntegratedPractice

Continuum

“People”Team

Med Safety, PI, & Risk Mgmt

Rx PracticeClinical Care

Business ofPharmacy

Rx PracticeOperations

Spheres of Accountability



15

ACCOUNTABILITIES?

16

A Proven Leadership Model

LEADERSHIP


IntegratedPractice

Continuum

“People”Team



Business ofPharmacy


Spheres of Accountability



17

Pharmacy Interfaces with all Disciplines and Departments

PhysiciansMedical Surgical & O.R. Inpatient Ambulatory & E.D.

NursingAdministrative InpatientAmbulatory

Quality Experimental medicine & IRB All Clinical departments

Administration Operations

Supply Chain - Materials Mmgt

Finance Information Technology Human Resources Transitions of Care Project Planning Utilization Review Radiology Pathology

18

Accountability #1

The People Team

The first and most critical leadership accountability for the successful pharmacyis to build and sustain a team of people that:

• Practice with professional integrity first and always• Are unquestionably competent• Are caring• Are committed



19

Professional IntegrityHonestyProfessional principles

Always Patient firstAppropriate relationship to money Collaborative with the health care teamCommitment to highest principles of pharmacy ethicsCompliance with legal and regulatory requirements

Consistent positive and fair relationships with peoplePatients and familyOther members of pharmacy & the health care team

Commitment to professional competence and excellence through continual learning and education

PeopleTeam

20

CompetenceProfessional practice competencies

Leadership in “people” & relationship skills Clinical care – knowledge and appropriate use of drugs to

optimize outcomes for each patient Pharmacy basic operational responsibilities

Compounding and dispensing of drugsControl of drugs across the continuumAssuring medication safetyAppropriate application and maintenance

of technology/IT Leading the “Business of Pharmacy” at the C-suite table Regulatory, accreditation, and legal compliance

PeopleTeam



21

Caring

Genuine concern and care for patients and familyMedication safetyOptimal clinical outcomes from drug therapyFiscal responsibility for costs of drugs and overall

patient careIntegration of pharmacy care and drug therapy into

the appropriate overall care of each patient across the continuum

Always honor the “grandmother rule”

PeopleTeam

22

CommitmentHighest principles of pharmacy practice

Clinical patient care and positive outcomesPharmacy operational responsibilities

Compounding & dispensing, safety, accuracy, and efficiencyConsistent delivery of safe and efficient pharmacy

services, oversight, and controls for:All patients in all areas24 X 7 Across the continuum of care including clinics, ambulatory

and specialty areas, etc.Demonstrated commitment through example

regardless of hours, personal comfort, convenience, or schedules

PeopleTeam



23

Critical Elements

Communications – up, down, & sidewaysClear roles for everyone (= accountability) ...

“I am______ and this is what I do and what I am responsible for!”

Recruiting, orientation and trainingA sense of belonging to the team with shared

vison.. Job satisfaction = RetentionFoster shared “culture of leadership”

PeopleTeam

24

It’s final results that count…



25

Wea

k

Relationship

Exp

erti

seInvestigate colleagues’ concerns about issues beforehand.Network beforehand to ensure support.Involve others who have stronger relationships to persuade your case.

Network before to ensure support.Involve others who have stronger relationships and expertise to persuade your case.Involve outside expert and credible references that validate your position.Seek early proofs/successes/ prototypes of your position beforehand as confirming evidence.

Persuade directly using techniques of framing, compelling positions/evidence, and emotional connection.

Credibility Tactic Grid

Involve outside experts to validate.

Bring in externally validated evidence (e.g.,market research, consultants’ reports).

Create pilots/prototypes/mini-successes that prove your position.

Jay Conger

26

Metrics and Success Measures

Recruiting success, retention and turnover rates360 degree evaluations + constructive actionComplaints and employee legal suitsResults: productivity, service, & safety/outcomes The “fun factor”…..makes coming to work “ok”“Faces” of the pharmacy team……shared belief

regardless of today’s trials…..tomorrow can and will be a better day!

Creating the winning culture

PeopleTeam



27

#2

The Business of Pharmacy

Leadership must give the “business of pharmacy” the same critical attention and expertise as other professional accountabilities

28

Eight Critical Elements To Address

Have we started with the strategic planning process?Are we buying drugs at best possible advantage?Are sound business principles and practices being

applied to all pharmacy operations?Are patient billing and revenue processes sound and

routinely monitored?Are efficient technologies in place?




29

Eight Critical Elements To Address Are pharmacy resources, including drugs, supplies,

and manpower properly controlled and managed?Drug expense 80/20 reportClinic revenue by HCPCS code versus cost x volumeAre the units correct in the charge master?Pharmacy participates/leads revenue cycle team

Are patient outcomes and medication safety concerns properly balanced with financial considerations?

Are all pharmacy entrepreneurial opportunities identified, & pursued?


30


Positive regular audits of basic pharmacy fiscal processesSound fiscal metrics – costs and revenues/CMI adjusted

patient day or CMI adjusted admission Budget performance & action plans for variancesExpenses & RevenueCost based budget determined by patient type volumes

Patient care services that include cost, safety, and performance efficiency




31


32

Acc

ount

able

Pay

men

t at R

isk

Care Transformation

Lower unnecessary utilization for the ACO population.Have sufficient ACO population.Careful not to undermine non-ACO revenues.

Efficient Delivery System Transformation Inadequate physician alignment.

High cost pathways.

Poor analytics for measurement

The Accountable Care Transition (or one foot in each of two canoes)

Financial

Care Delivery

Synchronizing change



33


34

Your Hospital Schedule 1.Ambulatory Clinic Administered DrugsWeighted Average Drug Cost Analysis

Drug Dose Cost Mark - up

Billing code -$ 0% InstructionsInsert Fiscal Year.

Expected Collection Payor Mix Weighted Insert billing code.Charge Rate % Payment Payment Generic drug name.

Cost per dose.HMO 1 Fee Schedule 10.8% -$ Percent mark-up.HMO 2 - 60.0% - 8.6% -$ Trade name for drug.Commercial - 69.0% - 2.0% -$ Dose (i.e., mg, mcg).HMO 3 - 37.9% - 21.7% -$ List insurers.Indemnity Insurance - 51.9% - 7.5% -$ Insert % chg or fee Medicare ( c )APC rate 1-1-19 Fee Schedule 19.3% -$ schedule.Medicaid - 44.0% - 5.4% -$ Insert fee schedule Other HMO - 54.0% - 9.7% -$ payment amount.Self Pay - 100.0% - 6.5% -$ Insert % "Payor Mix" Capitated Risk - 36.6% - 8.6% -$ Weighted payment is

100.00% -$ automatically calculated.

Summary of Net Payment Weighted Average Payment by Payor - All other values in Charge, Payment and Reductions Weighted Payment are calculated

Administrative Write-off 3.5% - for non-colored cells.Bad Debt 2.0% - Other 1.0% - Total Reductions 6.5% -

Insert values for write-off, bad debt etc.Adjusted Net Payment -$ All other values in Summary of Net Payment

and Net Revenue are calculated.

Summary of Estimated Net Revenue Adjusted Net Payment per avg high cost drug - Average cost per drug - Estimated Net Revenue -$

Fiscal Year

34



35

Outpatient Injectable Drugs Across Payors

36

The Business of Pharmacy Summary –Follow the Money

Inpatient pharmacyReduce drug costsUtilization management of medicationsSterile Products – re-insource to reduce costs

Clinic pharmacyDetermine profit margin on clinic injectable drugsMost clinic drugs have margin to cover costs

Rx



37

Critical Balance of Two Equally Important Spheres of Practice Accountability

Pharmacy PracticeClinical Care

Pharmacy PracticeOperations

38

Two Equally Important Accountabilities Depend on Fiscal Balance as Well






39

Assurance of appropriate drug therapy outcomes for all patients through sound

comprehensive clinical monitoring and pharmacy

practices

Pharmacy Practice – Clinical CareAccountability

#3

40

Critical Elements To Address

Order entry & clinical monitorsStandardized order sets, formularies and formulationsMedication reconciliation & profile review, interaction

with prescriberPatient rounds and drug therapy outcomes review,

patient educationClinical vs cost review = actions Critical balance vs operations priorities




41


Clinical monitors vs actions reviewsMedication errors & ADE’s Interventions for care and cost reasonsMedication reconciliation and patient counselingComparative cost vs outcomes Length of stay vs readmission ratesHospital infections vs resistance ratesSatisfaction surveys


42

All the operational processes and related medication use

responsibilities including order entry, dosage

preparation, compounding, and delivering drugs to

patients.

Pharmacy Practice – OperationsAccountability

#4



43

Critical Elements To Address

Order entry processCompounding of medications

and intravenous admixturesDispensing, distribution, and control

of all medicationsEffective use of various technologies including

IT, robotics, cabinets, etc.Critical balance with clinical practice priorities


44


Compounding and dispensing volumes and efficiency measures

Dispensing errors and “near misses”Order entry accuracy/errorsControlled drug errors, audits, & variancesTurnaround times (order entry, doses, stats,

code blue response, etc.)Service complaints & satisfaction surveys




45

…All interrelated critical roles for today’s health system pharmacy leadership

Medication Safety, PerformanceImprovement & Risk Management

#5

46

Critical Elements to Address

Building a comprehensive “Medication Safety Net”Order entry and clinical monitorsDispensing & compoundingStock controls – high risk drugs, quantities, strengthsLabeling standards and controlsSpecialty areas - controls & checks/ balances (nursery,

pediatrics, oncology, ED,OR, etc)

Med Safety, PI, andRisk Management



47


Performance Improvement (PI)Errors (dispensing & administration)Turnaround timeLength of stay, re-admissionsCost of drugs and patient staySatisfaction surveys (patient, nurse, MD)Efficiency metricsPatient/family, nurse, MD complaints

Risk Management = all of the above


48


Various indicators (med safety & PI)Errors (dispensing, administration)Turnaround timeSatisfaction surveys (patient, nurse, MD)Length of stay, re-admissionsCost of drugs and patient stayEfficiency metricsPatient/family, nurse, MD complaints

Risk ManagementLawsuits and costs of litigation




49

Accountability for a wide array of demanding

pharmacy regulatory, accreditation, and other

compliance requirements

Pharmacy Corporate Compliance

#6

50

Critical Elements to Address Regulatory complianceState board of pharmacyDEAFDACMS

AccreditationTJCASHP ResidenciesACPE Colleges

Corporate compliance – pharmacyConflict of interestContracting & purchasingBilling and pricing, 340b compliance

Pharmacy CorporateCompliance



51


Regulatory compliance reportsState board of pharmacyDEA, FDA, CMS

Accreditation findings reportTJCASHP ResidenciesACPE

Corporate compliance – pharmacy audits and reports (DSCSA, 340b, etc.)

Pharmacy CorporateCompliance

52

Accountability for integration of services within pharmacy, with other disciplines, and seamless integration of care across the continuum.

Pharmacy Practice Integration

#7



53


Acute care pharmacy integration across the continuum to ambulatory and other patient services

Integration and critical balance within the pharmacy practice - operations versus clinical services

Integration of pharmacy operations & clinical services with the College of Pharmacy

Expansion of technician utilization and responsibilities

Integrated Pharmacy Practice

Continuum

54


Critical integration of pharmacy servicesand patient care beyond pharmacy’s “walls”, including building an effectiveteam with other disciplines, including:MedicineNursing Health system leadership (CEO, CFO, legal

counsel, etc)Information technology

Integrated Pharmacy Practice

Continuum



55

Metrics and Success Measures A seamless pharmacy model that

effectively functions beyond the “walls” of pharmacy OperationallyClinicallyFinancially

Assure patients and their drug therapy needs don’t fall into the “seams” of the system

No patient in any area of the continuum fails to receive appropriate pharmacy care

Integrated PharmacyPractice

Continuum

56

The New Leadership Model

Each accountability must be fully addressed with an ongoing strategy to focus andachieve, sustain, and balance for ultimate leadership success

LEADERSHIP


IntegratedPractice

Continuum

“People”Team



Business ofPharmacy


Putting it all together. . .

. . . In balance!



57

How do we do all this?

58

Our success stories all demonstrate a common answer and…It’s not an administrator who favors pharmacyIt’s not a wonderfully positioned and talented “chief

pharmacy officer”It’s not a “I can do it all myself” positional leaderIt’s not even a gifted charismatic pharmacy leader….. the answer demonstrated most consistently

is……

A Pharmacy team with a new and unique shared “Culture of Leadership”



59

This new culture recognizes and fosters the leadership development of every member of the pharmacy team including…

A New Culture of Leadership?

60

A “Big L” leader who is positioned appropriately in the organization and is highly competent, yet comfortable delegating and leading others to achieve results

“Small L” or situational leader pharmacists who can lead a team, solve a problem, make decisions, handle a situation & accept responsibility for pharmacy accountabilities

A New Culture That Includes:



61

Leading into the Future as a SystemCentral warehousing /distributionOral solid repackagingCentralized filling of ADM’s Sterile Product preparationCode Cart Preparation Anesthesia traysControlled substance monitoring Shared clinical services Shared medication order confirmation Internal process controls - compliance Pre-admission medication historiansOptimization of resources

62

A New Culture of LeadershipThis new culture recognizes and fosters the leadership

development of every member of the pharmacy team including:

Technicians and supportive personnel who have proven competence and leadership capabilities to lead a tech team

A shared understanding and commitment of the pharmacy team of leaders to the 7 accountabilities

Every member knows, understands, and accepts their personal leadership responsibilities



63

Not Always A Perfect Symmetrical World!

LEADERSHIP


IntegratedPractice

Continuum

“People”Team



Business ofPharmacy


Recognize that every system is a constantly changing model.

+ or -

- + or -

+

-

+

-

64

New “Culture of Leadership” Promotes Shared Responsibility

LEADERSHIP


IntegratedPractice

Continuum

“People”Team



Business ofPharmacy


All are essential for success!



65

Summary: “Top 10” Traits of SuccessRecognition & command of all 7 “spheres of accountability”

A pharmacy team with a shared “culture of leadership”

An effective leadership development program

Commitment to balancing operational vs clinical practice

Pharmacy leader structured and empowered at correct level within the organization with ongoing communication

66

If You Are Feeling Overwhelmed –Follow these Steps

Start with your not to do list Ruthlessly eliminate all time-wasting, non-productive, life taking, soul-

draining distractions

Get your to-do list out of your headCreate a consistent system to record everything you need to do

Putting in on your calendar clears your mind, giving you permission not to think about it

Break your to-do list into actionable steps to avoid immobilization Put down your next step in your project

Prioritize what’s most importantChoose what’s important over what is urgent – Quadrant 2

Take the next achievable step that is prioritized to lead to success Stay calm, move steadily, eliminate emotion



67Seven Habits of Highly Effective People-Covey

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Conclusions

It’s been my pleasureAny other questions?

E-mail: [email protected]

Thanks for yourattention !



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DATA DRIVEN WORKFLOWS

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OBJECTIVES

• Discuss the methodology for data driven workflow optimization

• Review how to select and interpret metrics that measure the effectiveness of the pharmacist workflow

• Discuss ideas for engaging the pharmacist staff in workflow modification

• Review the results of a data driven workflow modification



71

METHODOLOGY

• Workflows should be designed to encourage all staff members to practice at the highest level of their licensure.

• Workflow mapping is essential to understanding where inefficient overlap, duplication, or gaps may be occurring.

• Every workflow or process improvement map typically has 3 routes:

• Perception: what we believe is happening

• Supported by “soft” data

• Reality: what is actually happening

• Identified by “hard” data

• Ideal: what should be happening

• Goals of the workflow modification

72

METHODOLOGY

• Staff feedback is the primary driver of the ”soft data” and directly drives the perception route

• 1st step is to ask staff to list their day to day responsibilities

• Compare the lists and make note of the variation in the responses

• Utilization of workflow mapping and a drill down technique such as the “5 Why’s” will transform “soft data” to ”hard data” and help identify workflows or process improvements that may be indirectly related

Excessive Phone Calls in Pharmacy (Problem)

1st Why: Why are they

calling? Missing

Medication

2nd Why: Why is the medication

missing? Pt

transferred from ICU overnight

3rd Why: Why was the 10am dose sent the night before? It printed on the 6pm IV

Batch to make the last delivery

Adjust IV batch times to decrease

time between dose due

and delivery



73

WORKFLOW STANDARDS: PHARMACIST

• Dispensing activities

• Cart/Batch Fill

• Initial Doses

• Missing Medication Requests

• Order Processing

• Order volumes by unit and hour

• Pharmacist turn around time **SELECTED TARGET: 34.9 Minutes Overall Average**

• Clinical Interventions

• Time and type of documentation

74

ASSESSING THE WORKFLOW

Pharmacist AVG Turnaround Time in Min

RPh 1 41.6

RPh 2 31.9

RPh 3 32.7

RPh 4 20.9

RPh 5 60.2

RPh 6 52.4

RPh 7 26.5

RPh 8 54.7

RPh 9 30.3

RPh 10 23.8

RPh 11 27.2

RPh 12 29.5

RPh 13 38.4

RPh 14 36.4

RPh 15 36.4

RPh 16 76.2

RPh 17 32.5

RPh 18 46.1

RPh 19 48.1

RPh 20 26.9



75

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ENGAGING THE PHARMACIST STAFF

• Show the staff hard data which is the reality of the current workflow and clearly explain the goals of the proposed changes.

• Be prepared to challenge the staff to work through their own soft data.

• Teach them the 5 Why’s philosophy and have them drill to the true issue

• Don’t allow the discussion to get hung up on one in a million scenarios

• Discussion should focus on pharmacy owned and driven processes

• Additional education is typically not an effective countermeasure/intervention

• Don’t allow the why to drive to a solution based in nursing or another department

• Do not assume staff will want to remain with current job assignment

• Registration of interest period: way for staff to submit directly their level of interest by ranking the available job assignments.

• Opportunity to identify potential in staff that may not have previously spoken up



77

IDENTIFIED OPPORTUNITIES

• Peaks in TAT line corresponded to the departure times of the common shifts.

• Staff believed the highest order volumes were only until 5pm, but the hard data demonstrated a need until 10pm (Perception Reality)

• Solution: expand services until 10pm (Ideal)

• Largest peak was due to the overnight being away from order verification to perform final checks on overnight cart fill and IV batch

• Staff believed morning cart was going out late due to inefficient overnight pharmacist, but hard data proved the “efficient” pharmacist was ignoring the queue to complete the cart check. (Perception Reality)

• Solution: adjust cart delivery and batch times to avoid placing responsibility on overnight and reduce the amount of time between the polling and delivery (Ideal)

• 7am until 1pm has TAT at or above the overall average despite the greatest number of pharmacists onsite

• Staff believed the centralized pharmacists that monitored the all queue would be able to assist more than they were able to. (Perception Reality)

• Solution: decentralize all but one pharmacy and absolve the centralized pharmacist of over verification (Ideal)

78

WORKFLOW MODIFICATIONS

• Pharmacists were moved to an 8 hour shift to allow for smoother transition in pharmacist staffing levels

• Decentralized pharmacists assignments changed to reflect order volumes

• Other factors considered included pharmacy consults and nursing turnover

• Decentralization of all but one pharmacist in central pharmacy.

• Previously there were 2-3 pharmacists in the central pharmacy from 6am until 8pm.

• Pharmacist assigned to central pharmacy was removed from order verification.

• Primary function is final product verification, controlled substance management, and adherence to sterile compounding standards.

• Allowable in the State of Florida as long as there are sufficient pharmacists on the premises (defined as immediate building and readily contacted)

• Pharmacy phone tree changed to eliminate all phone calls to central pharmacy.

• Calls are thrown to the pharmacist responsible for managing the nursing unit.



79

ASSESSING THE INTERVENTIONS

Pharmacist Prior Workflow AVG TAT New Workflow AVG TATRPh 1 41.6 31.3RPh 2 31.9 18.3

RPh 3 32.7 12.3RPh 4 20.9 14.1RPh 5 60.2 20.6RPh 6 52.4 21.6

RPh 7 26.5 15.8RPh 8 54.7 23.7RPh 9 30.3 21.1RPh 10 23.8 13.4

RPh 11 27.2 18.0RPh 12 29.5 23.7RPh 13 38.4 16.6RPh 14 36.4 16.6

RPh 15 36.4 19.0RPh 16 76.2 28.8RPh 17 32.5 19.3RPh 18 46.1 34.6

RPh 19 48.1 43.4RPh 20 26.9 16.5

Overall Average 34.9 19.1

80



81

SECONDARY OUTCOMES

• Missing Medication Requests:

• Decreased by 25%

• Why?

• Carts releasing from pharmacy in a more timely manner

• Central pharmacist and techs able to optimize ADCs in live time

• Initial Doses Sent:


• Why?

• Able to focus on optimization of the ADC

• Able to eliminate redundant/low moving items from formulary

82

SECONDARY OUTCOMES

• IV Batches:


• Why?

• Changed batch to every 6 hour run time to narrow likelihood of sending discontinued doses or doses to pre-transfer nursing unit

• Credits


• Why?

• Because the central pharmacy staff could focus on dispensing activities and inventory optimization.



83

PRE & POST WORKFLOWS

• Pre-Modification:

• Centralized pharmacist 6am-4:30pm, 9:30am-8pm, 12:30-11pm, and Overnight 8pm-6am

• Decentralized Pharmacists: 4-5 from 7am-5:30pm Monday-Friday, 1 pharmacist 12:30-11pm

• Overnight pharmacist going without breaks and being left alone from 11pm until 6am

• Heavy reliance on PRN/POOL staff and residents for weekend coverage

• Post-Modification:

• Centralized Pharmacists: 5am-1:30pm, 11am-7:30pm, and Overnight 7pm-5:30am

• 11am-1:30pm overlap for break coverage and controlled substance receiving/waste

• Decentralized Pharmacists: 10

• 7 pharmacist arrive between 5am and 8am (staggered based on assignment volumes by hours)

• 1 pharmacist arrives at noon to assist with break coverage and prepare for pharmacists departures beginning at 1:30pm. Covers all critical care units.

• 2 pharmacists arrive at 3pm to receive report from remaining inpatient units as they begin to depart at 3:30pm.

• 1 covers all remaining inpatient units

• 1 covers the ER and all procedural areas

84

DATA DRIVEN WORKFLOW

• Allowed us eliminate redundancies in the pharmacist workflow and encourages the pharmacist to practice at the top of their license.

• New workflow allows for pharmacists to participate in :

• Interdisciplinary Rounding in all Critical Care Units and Step Down Units

• Code Blue Response from 6am until 11pm

• Stroke Alert Response from 6am until 11pm

• Represent pharmacy on various committees (i.e. Critical Care, Code Blue, Neurology, Trauma, etc.)

• Expand their day to day practice to include some of their passions:

• Medication Safety Officer

• Nutritional Support Rounding

• Hazardous Sterile Preparation Certifications

• Clinical Intervention documentation in Sentri7 increase by 3% over the prior workflow.

• All of these outcomes were achieved without expanding the number of pharmacist FTEs, the new pharmacist workflow requires 2.2 less FTEs than the previous workflow.



85

CONCLUSIONS

• When mapping your workflow the goal should be to develop an ideal workflow that encourages the pharmacist to practice at the highest level of their license.

• Hard data and reality based workflow assessments are needed in order to make strides towards an ideal workflow.

• Eliminate generalized work flow assignments such as all queue or a singular PK pharmacist.

• Give pharmacists a clear assignment and encourage they engage each other if assistance is needed.

• Prevent underperforming staff from hiding in the crowd

• Allows for peer to peer comparison

• When reviewing your opportunities for improvement it is crucial to understand how they may be related so the most productive course of action can be taken.

86

Disclosure: The information contained in the presentation is for Community Health System employees and hospital affiliates and is not for external distribution and/or use. The presentation may contain information that is proprietary, confidential, or legally privileged or protected. It is intended only for the use of Community Health System employees and hospital affiliates. Do not deliver, distribute or copy the presentation and do not disclose its contents or take any action in reliance on the information it contains outside of Community Health Systems and hospital affiliates.



88

UPDATE INFORMATIONJERRY REED, MS, RPH, FASHP, FASCP

89

LEGAL & REGULATORY

EPA Management Standards for Hazardous Waste Pharmaceuticals

Inmar’s EXPIdentify

State adoption of EPA revised regulations

Drug Diversion Reporting

Joint Commission requirement for deterring diversion - Quarterly Attestations for Policy Compliance

Controlled substance policy revisions

Investigation and reporting of events

Additional Controls of Non-Scheduled Products



90

OPERATIONS

Reverse Drug Distribution

Returns sent prior to inventory

Stericycle for non-creditworthy products

Stericycle CSRx for controlled substance disposal (if state required)

Physical Inventory Preparation

Training video developed by Cardinal and Inpharmics

Sectional sub-totals

Influenza Vaccine

Policy and Procedure Availability

91

FINANCE

Inventory Optimization Central pharmacy and automated dispensing cabinets Omnicell implementation Project status IV fluid storage

Reverse distribution (Inmar) Wholesale distributor (Cardinal) returns

Initiatives 3Q2019 Quarterly Initiatives Savings Opportunity Reports

Metrics

Drug Spend as a PerCent of Net Revenue (DS%NR)

Drug Spend per Adjusted Admission (DS/AA)

Anti-Infective Drug Spend per APD (AIS/APD)



92

EXPENSE REDUCTION CHALLENGE – 4Q2019

Return excess stock for credit

Decrease drug waste with drug transfers

Supplies

Reduce stock levels and reorder quantities

Permanently readjust PAR levels

Crash carts and kits

Premixed products

Outpatient services

Excess drugs due to implemented initiatives

Indigent drug programs

IV production

What percent reduction in spend can you achieve by 12/31/2019?

93

NATIONAL PHARMACY WEEK OCTOBER 20-26, 2019

2019 Pharmacy Educations3.proce.com/res/pdf/CHS2019Oct16Handout.pdfThe Business of Pharmacy CHS...

Documents

Transcript of 2019 Pharmacy Educations3.proce.com/res/pdf/CHS2019Oct16Handout.pdfThe Business of Pharmacy CHS...