Steve Rough

Effective use of workload and productivity monitoring tools in health-system pharmacy, part 1.

PURPOSE The current status of external and internal workload and productivity measurement systems and strategies to improve their use to maximize overall pharmacy department operational performance and staffing effectiveness are described. SUMMARY The use of operational benchmarking is increasing within health systems as a tool for continuously measuring and improving departmental performance and evaluating departmental success. Unfortunately, software used for benchmarking purposes is available through a limited number of commercial vendors and consultants, and these systems are unable to effectively measure department operations and overall performance. The theoretical value of benchmarking and productivity measurement systems, including a description of the various definitions, tools, and data sources for comparing pharmacy productivity data, is summarized. The limitations of commercially available vendor productivity monitoring systems and desired strategies for improving their use are also reviewed. Preferred productivity and cost metrics for measuring pharmacy department effectiveness are suggested, and strategies for obtaining value from external and internal productivity monitoring systems are explored. CONCLUSION Challenges with external operational benchmarking and internal productivity monitoring systems are numerous. These systems rarely measure the quality of pharmacy services provided and their effect on patient care outcomes and the total cost of care. Benchmarking vendors must modernize their software and develop internal checks to confirm data integrity in order to make their products more useful and reliable. In addition, data supporting the patient care role of the pharmacist should be integrated into all productivity monitoring systems and be used to demonstrate the positive impact of pharmacy services on the total cost and quality of patient care.

ASHP Statement on bar-code-enabled medication administration technology

The American Society of Health-System Pharmacists (ASHP) encourages health systems to adopt bar-code-enabled medication administration (BCMA) technology to improve patient safety and the accuracy of medication administration and documentation. To support the goal of having all medications electronically verified before they are administered, BCMA systems should be used in all areas of health systems in which medications are used. Pharmacists must be involved in the interdisciplinary planning, development, implementation, and management of BCMA systems and must ultimately be responsible for developing and maintaining the infrastructure required to ensure BCMA success. Health systems deploying BCMA programs must provide the funding and staffing necessary to permit pharmacists to fulfill this role. ASHP urges the Food and Drug Administration (FDA) and other regulatory agencies, standard-setting bodies, contracting entities, health systems, and others to mandate that pharmaceutical manufacturers use symbologies that are readily deciphered by commonly used scanning equipment to code for the National Drug Code (NDC), lot number, and expiration date on all unit dose, unit-of-use, and injectable drug packaging. Pharmaceutical manufacturers should also provide all medications used in health systems in unit dose packages. FDA, pharmaceutical manufacturers and packagers, and the manufacturers of BCMA systems should collaborate to minimize or eliminate the causes of false rejection of valid medication doses. Certain characteristics of the current NDC identification system contribute to the burden of implementing BCMA systems, and ASHP urges stakeholders to participate in efforts to develop a system that more reliably identifies the unique drug (or combination of drugs), strength, dosage form, and route of administration. Although bar-coding systems are currently a widely used point-of-care technology, ASHP recognizes that other types of machine-readable coding (e.g., radio-frequency identification) may evolve. ASHP supports the use of new technologies that are as effective as or improve upon existing systems and believes the principles outlined in this statement apply to such systems. ASHP urges further research on such systems as well as research that will definitively determine the extent to which BCMA systems reduce preventable medication errors and provide a financial return on investment for health systems.

Comparison of a hybrid medication distribution system to simulated decentralized distribution models

PURPOSE The results of a study to estimate the human resource and cost implications of changing the medication distribution model at a large medical center are presented. METHODS A two-part study was conducted to evaluate alternatives to the hospitals existing hybrid distribution model (64% of doses dispensed via cart fill and 36% via automated dispensing cabinets [ADCs]). An assessment of nurse, pharmacist, and pharmacy technician workloads within the hybrid system was performed through direct observation, with time standards calculated for each dispensing task; similar time studies were conducted at a comparator hospital with a decentralized medication distribution system involving greater use of ADCs. The time study data were then used in simulation modeling of alternative distribution scenarios: one involving no use of cart fill, one involving no use of ADCs, and one heavily dependent on ADC dispensing (89% via ADC and 11% via cart fill). RESULTS Simulation of the base-case and alternative scenarios indicated that as the modeled percentage of doses dispensed from ADCs rose, the calculated pharmacy technician labor requirements decreased, with a proportionately greater increase in the nursing staff workload. Given that nurses are a higher-cost resource than pharmacy technicians, the projected human resource opportunity cost of transitioning from the hybrid system to a decentralized system similar to the comparator facilitys was estimated at

Determining the feasibility of robotic courier medication delivery in a hospital setting

229,691 per annum. CONCLUSION Based on the simulation results, it was decided that a transition from the existing hybrid medication distribution system to a more ADC-dependent model would result in an unfavorable shift in staff skill mix and corresponding human resource costs at the medical center.

Design, implementation, and evaluation of a thrice-daily cartfill process

PURPOSE The feasibility of a robotic courier medication delivery system in a hospital setting was evaluated. SUMMARY Robotic couriers are self-guiding, self-propelling robots that navigate hallways and elevators to pull an attached or integrated cart to a desired destination. A robotic courier medication delivery system was pilot tested in two patient care units at a 471-bed tertiary care academic medical center. Average transit for the existing manual medication delivery system hourly hospitalwide deliveries was 32.6 minutes. Of this, 32.3% was spent at the patient care unit and 67.7% was spent pushing the cart or waiting at an elevator. The robotic courier medication delivery system traveled as fast as 1.65 ft/sec (52% speed of the manual system) in the absence of barriers but moved at an average rate of 0.84 ft/sec (26% speed of the manual system) during the study, primarily due to hallway obstacles. The robotic courier was utilized for 50% of the possible 1750 runs during the 125-day pilot due to technical or situational difficulties. Of the runs that were sent, a total of 79 runs failed, yielding an overall 91% success rate. During the final month of the pilot, the success rate reached 95.6%. Customer satisfaction with the traditional manual delivery system was high. Customer satisfaction with deliveries declined after implementation of the robotic courier medication distribution system. CONCLUSION A robotic courier medication delivery system was implemented but was not expanded beyond the two pilot units. Challenges of implementation included ongoing education on how to properly move the robotic courier and keeping the hallway clear of obstacles.

Highlights of the Cleveland Clinic Pharmacy Practice Model Summit

PURPOSE Efficiencies achieved through a redesign of the central pharmacy cartfill process at a large academic medical center are reported. SUMMARY In an initiative to expand clinical pharmacy services in a budget-neutral manner, pharmacists at the University of Wisconsin Hospital and Clinics (UWHC) led the transition from a once-daily to a thrice-daily medication cartfill model designed to better align pharmacy operations with patterns of medication ordering, delivery, and order discontinuation. A pre-post analysis demonstrated several benefits of the shift to thrice-daily cartfill, including a 32.7% decrease in the mean daily number of extemporaneously prepared oral doses. Overall, the new cartfill process resulted in reduction in lead times for three of four peak delivery periods, roughly a 55-65% reduction. During the postimplementation period, the frequency of requests for missing medication doses through the electronic medical record (EMR) system increased from 1.13% to 1.43%; however, this increase may have been the result of improved nurse adherence to EMR protocols for requests for missing medications. CONCLUSION Implementation of a thrice-daily cartfill process and ancillary changes at UWHC resulted in a 2.1% increase in cartfill doses dispensed, a 44.1% decrease in first doses dispensed, and a 42.9% decrease in the number of medications returned to the central pharmacy. This resulted in a reduction in waste within pharmacy operations and allowed for redeployment of two technician full-time equivalents to expand pharmacy services.

Evaluation of the Impact of Computerized Prescriber Order Entry on Medication Use System Performance at an Academic Medical Center

Video recordings of the speeches given at the summit, synchronized with slides, are available with the full text of this article at [www.ajhp.org][1]. In November 2010, the American Society of Health-System Pharmacists (ASHP) kicked off its Pharmacy Practice Model Initiative (PPMI) with the PPMI

Creating organizational value by leveraging the multihospital pharmacy enterprise

Purpose To evaluate the impact of computerized prescriber order entry (CPOE) on 3 elements of medication use system performance: inpatient medication override dispense rates from automated dispensing cabinets (ADCs), medication first-dose turnaround time (TAT), and pharmacist perception of the medication orders management process. Methods A pre-post intervention trial design was used to assess each of the 3 medication use system elements. The intervention was CPOE implementation. The ADC override outcomes evaluated were the total number of overrides and the presence of appropriate documentation for each override. One week random samples of override data from the pre-CPOE and post-CPOE time periods were analyzed. The medication TAT outcomes studied were mean time from order entry by the prescriber to time of order verification and mean time from order entry by the prescriber to time of medication administration. Electronically collected data post CPOE were compared to manually collected data pre CPOE. The primary pharmacist perception outcome assessed was overall satisfaction with the medication orders management process. The pre- and post-CPOE data were collected through an electronic survey conducted after CPOE implementation. Results Following the implementation of CPOE, the relative number of medication override dispenses decreased by 58%, but documentation worsened by 73%. The mean time from order entry to order verification improved by 76%, and the mean TAT for intravenous antibiotics improved by 31%. Pharmacist overall satisfaction with the medication orders management process improved by 23%. Conclusion The implementation of CPOE resulted in improvement in each of the 3 medication use system elements assessed.

Testing of robotic medication-delivery systems

PURPOSE The results of a survey of multihospital pharmacy leaders are summarized, and a road map for creating organizational value with the pharmacy enterprise is presented. SUMMARY A survey was designed to evaluate the level of integration of pharmacy services across each systems multiple hospitals, determine the most commonly integrated services, determine whether value was quantified when services were integrated, collect common barriers for finding value through integration, and identify strategies for successfully overcoming these barriers. The comprehensive, 59-question survey was distributed electronically in September 2016 to the top pharmacy executive at approximately 160 multihospital systems located throughout the United States. Survey respondents indicated that health systems are taking a wide range of approaches to integrating services systemwide. Several themes emerged from the survey responses: (1) having a system-level pharmacy leader with solid-line reporting across the enterprise increased the likelihood of integrating pharmacy services effectively, (2) integration of pharmacy services across a multihospital system was unlikely to decrease the number of pharmacy full-time equivalents within the enterprise, and (3) significant opportunities exist for creating value for the multihospital health system with the pharmacy enterprise, particularly within 4 core areas: system-level drug formulary and clinical standardization initiatives, supply chain initiatives, electronic health record integration, and specialty and retail pharmacy services. CONCLUSION Consistently demonstrating strong organizational leadership, entrepreneurialism, and the ability to create value for the organization will lead to the system-level pharmacy leader and the pharmacy enterprise being well-positioned to achieve positive outcomes for patients, payers, and the broader health system.

Medication Errors Recovered by Emergency Department Pharmacists

In an article in the October 1, 2009, issue of AJHP, we described a robotic courier medication-delivery system that was studied in 2006.[1][1] A subsequent letter from Aldo Zini, president and chief executive officer of Aethon, Inc., manufacturer of the system, correctly stated that our research and