admin exam 2 Flashcards
Risk
Anything that threatens the ability of a person or organization to accomplish its mission
Some degree of probability that exposure to a hazard will lead to a negative outcome or consequence such as loss, damage, injury, or death
Risk in community pharmacy
Exposure to hazard
Negative outcome
Risk Management
The application of knowledge and experience to manage the occurrence of a potentially bad incident
Enterprise risk management: Involves using knowledge and experience to manage risks within a business or organizational environment
Risk Management
Not just the responsibility of the pharmacy manager
Pharmacists and pharmacy staff need to be aware of and directly involved in risk management strategies
Areas of risk in pharmacy
Historically have been
- Fire
- Theft
- Negligence related to prescription filling errors
- Injury on premises
- Competition
Speculative risk
Involves a chance of gain or benefit as well as loss
Speculative risks are not insurable
Examples
- Investments
- Operating/purchasing a pharmacy
- Small business ownership
Why do we care about what is insurable?
Pure risk
Risk in which there is only the opportunity of sustaining loss
There is no opportunity for gain
Pure risks are accidental, unanticipated, unavoidable
Include illness, death, fire, flood and accidents, medication errors
Insurance is designed to assist people in managing their exposure to these unanticipated or accidental risks
In order for pure risks to be insurable the loss must
Be measurable in dollar figures
Have a defined time and place
Be accidental for the insured
The probability of the event must be accurately calculated based on a similar cohort
The insured must have an insurable interest
The insurance costs must be reasonably priced
The risk management process
5 steps suggested in the text
- Establish the context
- Identify and analyze risks
- Evaluate and prioritize the risks
- Select and implement an appropriate risk management strategy
- Monitor decisions and update the risk management program
Establish the context
What are the goals of the risk management process?
What are the potential vulnerabilities of the business?
Do employees or patients risk injuries?
How might the reputation of the pharmacy/hospital suffer if a patient is injured due to a pharmacy error?
Can risk be avoided by not providing certain services or products?
Identify and analyze risks
Pharmacy managers should analyze the operation
Risks result from
- Activities inherent in the pharmacy practice operation
- Issues with physical facilities (exercise: name them)
- Issues with protected health information
Evaluate and prioritize the risks
Every risk cannot be addressed at one time so prioritization of risk is necessary
Some risks are common yet have a high degree of loss (shoplifting, rejected prescription claims)
Some risks are uncommon and have a very high degree of potential loss (fire, flood, patient harm from a dispensing error)
Select and implement an appropriate risk management strategy
Involves development of specific policies and procedures to avoid risk as well as to manage incidents where risk occurs
In the community setting what would these P & P include
In the hospital setting what would these P & P include
Monitor decisions and update the risk management program
Pharmacy managers must monitor compliance with current prevention strategies as well as develop new strategies (P & P ) to address changes in services
Pharmacy managers must monitor occurrences including reporting and follow-up
What is appropriate follow up to occurrences
Techniques to manage risks
Although risk is inherent in pharmacy practice different types of risk require different techniques to manage them including
Risk avoidance
Risk prevention
Risk absorption/retention
Risk sharing or transfer
Risk avoidance
This sounds like an obvious approach
Is impractical in the pharmacy business
Impossible to avoid the risks associated with drug distribution/prescription dispensing
There may be goods and/or services where the risk outweighs the benefit of providing them
- (ex: sterile compounding in community pharmacy)
Risk prevention
The most effective technique to manage risks
A goal of all pharmacists, regardless of the practice setting
A primary goal of all pharmacy managers
Involves taking steps to minimize the likelihood of its occurrence
Involves development of policies and procedures, standard work to prevent errors and improve patient safety
Risk absorption/retention
Pharmacies absorb some risk regardless of the practice setting
Community pharmacies absorb losses from shrinkage (shoplifting, employee theft, unsalable products) though they implement many strategies to prevent them
Hospital pharmacies absorb losses from expired compounded medications, unsalable products, billing errors though they implement many strategies to prevent them
Risk sharing or transfer
Another technique in risk management is to transfer the risk to another party
Pharmacies and pharmacists share risk with insurance companies
Insurance companies share risks by entering capitated agreements with providers (paying them a set amount per member per time period regardless of the actual amount spent on healthcare services)
Types of insurance for a pharmacy
Property insurance
Liability or casualty insurance
Business owner’s policy
Individual professional liability insurance
Umbrella or excess liability
Worker’s compensation
Emerging risks in modern pharmacy practice
OBRA 90
HIPAA
Others?
Risk with information management/technology
Strategic risk: Information technology systems must be compatible with the pharmacy’s goals.
- Pharmacies must constantly make choices between investing in technology and other types of resources
- Successful implementation of information technology projects is difficult and requires many financial and human resources
- Systems must integrate and interface with others within and outside the organization
Risk with information management/technology
Performance risk: the degree of uncertainty inherent in the procurement and application of information technology that may keep the system from meeting both its technical and operation goals
Operational risk: risk of loss resulting from inadequate or failed internal processes including people, systems and external events. Includes internal fraud, external fraud, system failures and the human-automation tradeoff
Risk with information management/technology
Psychosocial risk: the moral and legal issues related to the interaction of information technology and the safety and health hazards that technology poses to employees in the workplace. Includes repetitive-motion injuries.
Risks, Risk Management Techniques and Specific Strategies
Computer system malfunction/ avoidance/upgrade or replace system
Customer theft/ reduction/ install security cameras, utilize security tags, sequester high risk items
Forged prescriptions for controlled substances/ elimination/ do not stock controlled substances, avoidance/ implement policies and procedures for prescription verification of validity
Risks, Risk Management Techniques and Specific Strategies
Medication errors/ reduction/ utilize bar-coding systems, double checks on high risk medications
Misreading orders or prescriptions/ avoidance/ use CPOE or electronic transmission of prescriptions
HIPAA violations/ reduction/ designate a private patient counseling area
The managers’ role in risk management
Serve as liaison between upper management and pharmacy staff to promote quality and reduce risk in all aspects of pharmacy operations
To discuss risks, their occurrences and outcomes of the occurrences with pharmacy staff
To encourage reporting of near-misses and error data
Communication
The risks of not taking risks
What would they be?
- Not staying current with technology
- Not staying current with MTM and other patient-focused programs
- Not providing the goods and services that your customers want
Compliance with Regulations and Regulatory Bodies
The legal and regulatory environment that is external to a pharmacy practice organization can exert significant influence on both the organization and its members
Patients put their trust in their pharmacists
State and federal laws provide layers of protection to shield the public from pharmacy practice that can cause harm
Standards for pharmacists’ performance
Standard: something established by authority, custom, or general consent as a model or example
Standard applies to any definite rule, principle or measure established by authority
Standards for a pharmacist’s conduct and the operation of a pharmacy are derived from laws and from professional standards and values
Standards for pharmacists’ performance
Violation of these standards may result in litigation if a patient is harmed and may affect the licensure status of both the pharmacist, the manager and the pharmacy
In the most severe cases violation of these standards can result in civil liability and criminal prosecution
OBRA 90
Omnibus Budget Reconciliation Act of 1990
Requires proper patient records (What is included in this patient record?)
Requires prospective drug review (What is included in this review?)
Requires the offer of patient counseling (What is included in the counseling?)
Why is it important for the pharmacy manager to monitor compliance?
HIPAA
Health Insurance Portability and Accountability Act of 1996
The pharmacy manager must know
- Who is covered by the privacy rule
- What information is protected
- What the covered entity must do to protect information
- That appropriate documentation is maintained
HIPAA
The pharmacy manager must ensure and is responsible for
- Employee training
- Notice of privacy practices
- Definition of business associates including contracts
- Patient authorizations for release of PHI
- Ensuring that PHI is appropriately maintained and released
Civil law and liability concerns
Negligence is the key to the outcome of any lawsuit
Negligence: failure to do something that a reasonable and prudent person would do or doing something that a reasonable and prudent person would not do
How can you prevent this from happening?
Civil law and liability concerns
Background
Investigations into medication errors tend to focus on the front end or active end of the error (the front-line practitioner or pharmacist)
Human nature results in the desire to place blame on an individual when an error occurs
Effective approaches to medication error investigations focus on the latent end or blunt end factors (factors that contribute to errors at the organizational or system level) Systems issues
Latent failures
Weaknesses in organizational structure
May include faulty information management, lack of appropriate training and decisions made by upper management
May result from incomplete information such as missing allergy or diagnosis information, unclear communication of a drug order, lack of an independent double check system, lack of computer warnings, ambiguous drug references, drug storage issues and sound-alike/look-alike drugs
Latent failures
Properties of the medication use process or system
Categorized by the key element of the system in which they occur
- Patient information
- Drug information
- Communication of drug information
- Drug packaging, labeling and nomenclature
- Drug device acquisition and use
- Drug storage, stock and distribution
- Environmental factors
- Staff competency and education
- Patient education
- Quality processes and risk management
The ordering process
Errors occur due to
- Illegible handwriting
- Look-alike drug names
- Sound-alike names
- Ambiguous orders
- Abbreviations
What can be done to avoid these?
Illegible handwriting
Clarify prescriptions/orders
Ask for the indication or purpose of the medication
Institute double-check systems
Utilize electronic submission of prescriptions
CPOE
Sound-alike/Look-alike drugs
Clarify orders
Read back orders
Store medications separately
Discourage verbal orders
Require complete directions, strength, route of administration and indication for use
Tall man lettering
Ambiguous orders
Clarify the order including dosage form and route of administration
Avoid leading and trailing zeros
Avoid unnecessary decimal points
Use the metric system exclusively
Selecting medications
What is in place to prevent selecting the wrong medication (wrong drug or strength?)
When utilizing automated dispensing technology where can medication errors occur?
Confirmation bias: the phenomenon that when choosing an item, people see what they are looking for and once they think they have found it, they stop looking any further
Abbreviations
The ISMP has developed a list of unsafe abbreviations that should be avoided 100% of the time
The Joint Commission has instituted this list and monitors for the use of unsafe abbreviations during compliance visits
How does this list and avoidance of the unsafe abbreviations get instituted in the outpatient/community setting?
Sterile admixture preparation
The process has great potential for errors
- Patients are often more acutely ill
- Mediations delivered directly to the blood stream
- Most IV admixtures are clear, colorless, and water-based so they all look alike
- Greater chance of dosage miscalculations and incorrect measurement
Minimizing errors in the sterile admixture preparation process
Use commercially available unit-dose products whenever possible
Standardize concentrations and doses
Standardize preparation processes including labeling
Institute double-check systems for high-risk medications (What are high-risk medications?)
Utilize automated compounding equipment whenever possible
Pre-printed order forms
Utilized in hospitals to standardize work
What would be the advantages?
- Standard concentrations
- Standard monitoring practices
- Standard information for providers
- Decreases opportunity for errors in the prescribing process
Patient counseling and education
The pharmacist/patient interaction can often prevent a dispensing error
Important factors that play a role in preventing medication errors include
- Direct patient education
- Health care literacy
- Patient compliance
Error prevention through reporting and monitoring systems
A responsibility of the manager and pharmacy staff
Systems approach
What factors inhibit the reporting of medication errors?
- Inconsistent definition of errors
- A punitive approach
- Mandatory reporting systems
- Failure to improve systems
- Lack of feedback
- Complex reporting processes
- Concern for personal liability
- Low priority associated with reporting
Medication error reduction strategies
From highest power or impact to lowest
- Fail safes and constraints
- Forcing functions
- Automation and computerization
- Standardization
- Redundancies
- Reminders and checklists
- Rules and policies
- Education and information
- Suggestions to be more careful or vigilant
Medication error analysis
Analysis of pharmacy specific or medication specific errors having the potential to cause patient harm
Analysis of organizational aggregate data
Analysis of near misses (often not done)
Analysis of errors that have occurred in other organizations (often not done)
Must be shared with staff at all levels
Steps in the Development of a Business Plan
Identify an action plan
Assess critical risks and opportunities
Establish an exit plan
on the exam:
Risk
Hospital (mostly)
community
Business planning
Remediation
Value added services
Defining the Business or Program
Conduct a preliminary evaluation/explore the business concept
- Conduct a literature search
- Obtain published systematic literature reviews
- Search the internet
- Consider the size and receptivity of potential customers
- Consider potential revenue
- Seek the advise of others
Conduct Market Research and Analysis
Market = customers of the program
May be described geographically
Consider the demographics of the regional population
Consider that customers are not always patient. They may be physicians or other health care providers.
Conduct Competitor Analysis
Identify and gauge potential competitors
Understand the characteristics and market share of other similar businesses
Compare strengths and weaknesses of competitors to your proposed business
Competitors may be external (community pharmacy, consultant pharmacy) or internal (hospital)
Assess Clinical and Quality Requirements
Analyze applicable regulations and requirements
Include mandatory requirements as well as voluntary standards such as those endorsed by professional organizations
Accreditation issues must also be analyzed
Important to plan on compliance initially and over time
May involve consultation with experts
Influences work processes, implementation of technology and staffing
Define Processes and Operations
Involves planning of the optimal organizational structure (maybe with a link to the larger organization)
Initial staffing, personnel requirements and reporting relationships should be defined including job titles and job descriptions
Should initially determine the physical structure, equipment and resources required
Workflow, workload and policies and procedures are strategized
Develop a Marketing Strategy
Should be based on information from the previous steps
For a new business the marketing strategy should be divided into an initial marketing plan and an on-going marketing plan
Must include the method(s) for communicating and the message to be communicated to customers
Should include promotional as well as goals over the long term
Develop Financial Projections
Very important
Difficult to do, often based on many economic factors
Should demonstrate a positive benefit-to-cost ratio
All business plans do not generate revenue, some may be designed to save money, reduce the length of hospital stay, improve outcomes
Revenue should be based on the anticipated volume of business, changes to volume over time and dollars generated per unit of service
Identify an Action Plan
The action plan should detail the start and finish dates and list of responsible individuals for each task necessary to accomplish the objectives of the business plan
Should include a plan for monitoring and assessment of performance and progress of the program
Assess Critical Risks and Opportunities
Similar to the SWOT analysis
Must assess strengths, weaknesses, opportunities and threats to the business plan
Establish an Exit Plan
A formal protocol for determining when and why a decision would be made to terminate the business or program
Defines the steps taken if this decision to terminate is made
The exit plan should include an amount of time to meet initial goals
Should include a clear mechanism for notification to customers of the plan to terminate
Theory or Best Practice
There is a certain amount of cross over between all of these steps in the development of a business plan
Important to take a systematic approach
Learn from the expertise of others
Writing the Business Plan
The written business plan should include
- An executive summary
- Background and description
- Market analysis and strategy
- Operational structure and strategy
- Financial projections
- Milestones, schedule and action plan
- Critical risks and opportunities
- Exit strategy
- Conclusion
- Support documents
Background on hospital pharmacy management
Promising career option for pharmacists who enjoy the challenges of administrative work in an institutional setting
Hospital pharmacy managers oversee the operations of the pharmacy department that provides service 24/7 regardless of the hours of operation
Managers ensure that quality pharmaceutical services are provided according to accreditation, legal requirements, and professional standards
Role of the hospital pharmacy
To provide at all times an adequate supply of safe, effective, and quality medications in appropriate dosage forms consistent with the needs of the patients
To rationalize drug utilization in collaboration with the medical staff
What makes this different from community pharmacy practice?
Goals for the hospital pharmacy service and the manager
To provide the benefits of a qualified hospital pharmacist to patients and to the allied health professionals and institution
To assure a high quality of professional practice through the establishment and maintenance of standards of professional ethics, education, and attainment and promotion of economic welfare
To promote research in hospital pharmacy practice
Goals for the hospital pharmacy service and the manager
To disseminate pharmaceutical knowledge by providing an exchange of information among hospital pharmacists and members of a multi-disciplinary team
How do these goals differ from those in community pharmacy?
Responsibilities
Effective administration and management of a pharmaceutical service in a hospital
Development and provision of patient-oriented services
Maintenance of the hospital formulary through the pharmacy and therapeutics committee
Medication management
Budget management
Tasks of a Pharmacy Manager
Daily:
Scheduling
Operational/clinical situations
Drug movement/inventory discrepancies
Drug shortages
Occurrence reports
Technology downtimes
Hiring for open positions
Monthly:
Staff development
Staff discipline
Union vs Non-union
Strategic planning
Budget review
Flexible budgets
Variance review
Facility review
Regulatory concerns of the pharmacy manager
The Joint Commission
Center for Medicaid & Medicare (CMS)
Board of Pharmacy
Drug Enforcement Agency (DEA)
Department of public health (DPH)
Office of the inspector general (compliance)
Health Resources and Services Adm (HRSA)
USP chapters:
797, 800, 795
Human Resources (HR)
- Payroll, Discipline, FMLA
Organization / Department Structure
Every business has an organizational chart
- Defines who reports to which “manager”
- Defines scope of responsibility
- Maps out a structure for problem-solving
The larger the organization – larger the chart
- A small community hospital with 3 FTE pharmacists the Director of pharmacy may enter orders
- Large academic hospital manager will most likely not enter any orders
Who Does Pharmacy Report To?
Someone in the C-Suite
- Vice President of operations (VP, Operations)
- Chief Medical Officer (CMO)
- Chief Nursing Officer (CNO)
Other C-Suite members
- Chief Executive Officer (CEO), Chief Operations Officer (COO), Chief Financial Officer (CFO), Chief Informatics Officer (CIO)
A pharmaceutical service
Encompasses everything that is within the control of the hospital pharmacy department
- Clinical services
- Drug distribution
- Drug information
- Investigational drug services
- Medication safety
- Drug disposal
- Formulary management
Effective administration and management of a pharmaceutical service
Involves being totally familiar with the entire health care system and the specific functions of the hospital
Must consider the physical layout of the pharmacy department and the entire facility
Requires organization of the hospital pharmacy personnel
Requires an up to date manual of policies and procedures as well as continuous training and competency assessment
Patient-oriented services
Requires developing and maintaining a wide spectrum of clinical services geared toward your patient population
Some of these services are not geared towards drug dispensing activities (anticoagulation clinic, pain clinic, heart failure clinic, etc)
Fundamental to these services is the pharmacist’s knowledge of drugs, disease states, patient variables and the ability to interact routinely with other health care professionals and patients
Development and provision of patient-oriented services
Academic training in toxicology, pathophysiology and therapeutics as well as clinical experience provide the background for a pharmacist to provide patient-oriented services
- Post-graduate education
- Professional experience
- Research interests
Examples of patient-oriented services
Heart failure service
Antibiotic stewardship services
Surgical intensive care service
Cardiac intensive care service
Pediatric inpatient service
Solid organ transplant service
Oncology service
Medical intensive care service
Drug information service
Medication safety service
Maintenance of the hospital formulary through the P & T committee
The P & T committee promotes the rational use of medications through the development of rational policies and procedures for
- Medication selection
- Procurement
- Distribution
- Pharmacy and staff education
- Response to medication shortages
- Therapeutic substitutions
The managers role
To ensure that routine decisions about which medications to buy, how many and from what source are appropriately made
To focus on long-term planning and policies for improving safe and cost-effective use of medications
To ensure appropriate membership on the P & T committee including
- Medical staff
- Pharmacy
- Nursing
- Hospital administration
- Quality assurance staff
Hospital formulary management
Ultimately the responsibility of the pharmacy manager, goals:
- To conserve resources by limiting the formulary
- To eliminate generic and therapeutic duplication and to minimize the number of strengths stocked of the same medication
- To select medications for the formulary based on diseases and conditions treated at the facility
- To specify formulary medication of choice for common therapeutic indications
Hospital formulary management
To include second-line alternatives to medications of choice as needed while minimizing therapeutic duplication
To ensure that the hospital formulary corresponds with any national and regional standard treatment guidelines formally approved by the health system
To ensure best practices and evidence based practices are adhered to
The P & T committee
Basic functions include:
Ensuring that the national essential medicines list and local formularies are used appropriately in the facility (Check the WHO website for the lists)
Disseminating national standard treatment guidelines and developing institution-specific treatment guidelines for common diseases and medical conditions
Conducting medication use evaluations (MUE)
Conducting facility-based pharmacovigilance activities
The P & T committee
Monitoring medication usage at the facility
Providing education to hospital staff
Monitoring medication errors and adverse drug reactions and implementing systems changes to minimize events
Development, approval and monitoring of all therapeutic substitution, restricted drug and non-formulary medication use policies
Inpatient medication management
Drug distribution has historically been the primary function of the hospital pharmacy
Most hospitals utilize automated dispensing systems along with a system for distributing patient specific unit dose/unit of use medications
Challenges to medication management increase exponentially along with increases in the size of the institution
What are those challenges?
Inpatient medication management
Includes routine (at least monthly) inspections of all medication storage areas throughout the hospital in order to monitor expiration dates, refrigerator temperature logs, stock levels, patient specific medications and pharmacy returns
May include after hours medication distribution policies and procedures as well as an on-call pharmacy service to cover emergent situations
The Joint Commission required prospective order review by a pharmacist prior to administration of medications in the hospital setting. What challenges accompany this standard?
Drug Shortages
A significant number of drug shortages that impact the hospital pharmacy
Causes include:
- Reduced profit on generic, intravenous drugs
- Consolidated generic manufacturers in the industry
- Free market – No requirement to make drugs
FDA supported by FDAISA in July 2012
- 80% of raw ingredients for IV drugs from overseas
Compounding of medicationsUSP 797 (sterile) USP 795 (non-sterile)
Includes sterile and non-sterile products
Non-sterile product compounding is most often for a dosage form or concentration that is not commercially available
Sterile product compounding occurs in the clean room and must meet all USP 797 standards. Compliance is a focus of The Joint Commission Survey. What do we know about USP 797?
Policies and procedures as well as all levels of accountability are the manager’s responsibility
Budget management
One of the most critical responsibilities of the hospital pharmacy manager
Largest budget lines are the drug budget and costs of human resources
Budget management is most likely the main responsibility that the manager’s performance is evaluated on
Many other aspects of the operational management are delegated to supervisor’s, lead pharmacists, clinical specialists though the pharmacy director or manager is ultimately accountable
Human resource issues
It is often difficult to attract and hire qualified pharmacists and technicians
The do more with less philosophy is prevalent in this practice area
No back-up when staffing issues occur
24/7 coverage including holidays and overnights
Continuous education as well as competency assessment documentation is required and necessary
Staffing includes multiple levels of educational and professional requirements
Human resource challenges
Scheduling
Performance evaluations
Progressive discipline
Cross-discipline relationships
Per-diem staff
Communication within and outside of the department
Controlled substance management
Controlled substances are stored in the pharmacy and in the patient care areas in the automated dispensing units including the inpatient, outpatient and procedure rooms
One missing dosage unit requires investigation and immediate notification to the DPH and the BOP
Discrepancy resolution occurs daily and is performed by pharmacy staff as well as nursing, anesthesiologists and physicians
The most unique aspects of hospital pharmacy management
The manager may report to someone without any pharmacy background
The manager will most often interact with healthcare professionals outside of pharmacy
The manager will most likely spend more time focusing on satisfying outside customers than the pharmacy staff
The manager is responsible for systems that cross many disciplines
Regulatory bodies differ as well as accrediting bodies
Rewards
What are the advantages of practicing in a hospital pharmacy environment?
Multi-disciplinary practice
Based on best practices and evidence-based medicine
Constant learning environment
Level of professionalism
Career ladder (staff pharmacist up to Director)
How to become part of a pharmacy management team
Show off your leadership skills
- Volunteer for opportunities
- Demonstrate great teamwork with everyone
- Invest extra time
Look for additional training
- ASHP – Pharmacy Leadership Academy
- Human resource programs
Committee work in pharmacy organization
Types of Value-added Services
Point of Care Services
Case Management
Comprehensive MTM
Wellness/Health Promotion
Disease State Management
Clinical Services
Value Added Service
pill pack - a full service pharmacy that sorts your medication by the dose and delvers to your door
Pharmacists advancing public health
Population-based care
Active role in disease prevention, screening and wellness programs
Major role in immunization delivery
Implementing standing order for naloxone
Provider status
Integrating into pharmacy curriculum: MS degree in public health
First steps in developing a value-added service
Develop business plan
- Identify organization’s strategic plan and mission statement
- Explore ideas for value-added services
- Research (literature and pharmacy organizations)
- Work with administration (gain buy-in)
Evaluate the Market
Evaluate consumers
- Patients
- Providers
- Payers
Competitors
- What are others doing?
- Differentiate
Market Research
Survey/Questionnaire
Identify potential consumers
Identify potential services/programs
Willingness to pay for services
Perform a SWOT analysis:
Strengths
Weaknesses
Opportunities
Threats
Components of a value-added service
Data collection
Laboratory monitoring and screening
Medication management protocols
Patient education
Data Collection
Patient background and demographics
Medical history
Family history
Medication history
Laboratory data
Patient authorization for information
Reinforce to patient that this information is confidential and compliant with HIPAA
Laboratory Monitoring and Screening
Clinical Laboratory Improvement Amendments of 1988 (CLIA)
CLIA-waived test: must obtain a Certificate of Waiver(COW) allowing pharmacies to perform testing
COW must be renewed every 2 years
Medication Management
Develop a care plan
- What are the goals?
- What interventions will be done?
Develop a protocol
- Provide consistency of the care plan
- Supported by evidence based/national guidelines
Policy and Procedure Manual
Comprehensive “road map”
- Type of service and goals of service
- How patients are evaluated
- What happens at each visit
Educate/train pharmacy staff
Contents may include:
- Patient intake forms
- Protocols
- Teaching tools
- Guidelines and primary literature
Cost considerations
Space
Equipment
Salary
Training
License to perform lab tests
Equipment to perform tests
Educational tools; brochures, YouTube videos
Collaborative Practice Agreement
An agreement between single or multiple pharmacists and single or multiple providers
Improve patient care/outcomes
Describe the policy and protocol for delivering care
Assist with referrals
Disease Specific Protocols
Diabetes
Hyperlipidemia
Hypertension
Chemo induced nausea/vomiting (CINV)
Anticoagulation
Cardiovascular
Outcome Measures for the VAS
Important to establish outcomes prior to the start
Identify measurable outcomes
Collect baseline data before starting the intervention and then again after intervention to evaluate its impact
Examples of outcomes
Clinical outcomes
- A1c, BP, lipids, ER visits
Economic outcomes (costs)
- Hospitalization
- Prescriptions
- ER visits
Humanistic
- QOL-symptoms, perceptions, functional ability
Monitoring and Continuous Quality Improvement
Monitoring of outcomes
Success and failures
Feedback from pharmacy staff, patients, and providers
Create strategies for improvement
Types of Compensation
First party payers
- Patient is billed directly and pays for the service
Third-party payers
- The patient’s insurance company is billed for the service
Pricing methodologies
Fee-for-service
- Specific rate charged for service based on time or intervention
Resource-based relative-value scale (RBRVS)
- Service provided to the patient
- ICD-9 codes (diagnosis)
- CPT codes (patient visit)
Capitation-Fixed fee
Medicare
Medicare Modernization Act
- Pharmacists recognized as providers for Medicare Part D patients to deliver Medication Therapy Management (MTM) services
Pharmacists can also bill and receive payment for:
- Immunizations
- Durable medical equipment
- CLIA-waived laboratory tests
Pharmacy CPT codes for MTM services
99605-Initial face-to-face encounter with a patient (15 min)
99606-Subsequent follow-up encounter (15 min)
99607-Add on code for additional 15 min increments
Pricing considerations
Set a reasonable fee
- 2-3x salary revenue;
Fixed fees
- Max payers will pay
Efficient with time for service
Determine all costs
Utilize pharmacy technicians and interns
Strategies for Compensation
Credentialing
Prior authorization
CMS Medicare Provider
Appropriate CPT & ICD-9-CM codes
- CPT codes-procedure, visits, labs
- ICD-9-CM- health condition/specific disorder
Understand payer’s billing process
Summary
Develop a business plan to include objectives and goals of the value-added service
Identify the components of the value-added service
Identify costs and develop a strategy for compensation
Assess the outcomes of the value-added service
Collaborate with providers to maximize patient care and assist with referrals
Community pharmacy right for me?
Fast-paced environment
The most accessible healthcare provider
Clinical knowledge
Third-Party Billing
Soft/People Skills
The profession is developing:
- Vaccination Destination
- Medication Administration
- Point of Care Testing
- Prescriptive authority
Qualities of an Effective Pharmacist
Multi-tasking
Clinical decision-making
- Reliable tertiary sources from employer
- Supplement with personal sources
Follow directives from supervisor and align with corporate goals
- Script growth
- Technician schedules
The face of your employer
- Addressing patient/prescriber concerns
- Potential to represent a multi-billion-dollar company
Qualities of an Effective Manager
Leadership: Supervision of staff members
- Mass BOP allows for oversight of only ONE location at a time
Compliance:
- Federal, State, and Local laws & regulations.
- Company Policies
Delegate tasks: create a workflow that suits your pharmacy
- Building a staffing schedule
Performance management: Drive results and potentially discipline staff
Set goals & Execute them: Realistic and attainable goals that have a strategy on how to reach them
Financial: Understanding reimbursement patterns & methods to grow the business consistently
Friendly
Goals – a select few…
Pharmacist
- Patient safety and advocacy
- Use of knowledge acquired during school
- Financial livelihood
Patient
- To achieve positive healthcare outcomes (to get well)
- Efficient and positive interactions with the pharmacy
- Save money on prescription costs
Employer
- Achieve mission statement and live company culture
- Gain market share and reinvent self
- Ensure financial sustainability
Company Culture
What does the company represent?
- Mission Statement
- Written document that defines company culture
- Summarizes why a business exists
Vision
- Description of long-term goals
Evaluating Company Culture:
- Method to receive feedback from associates
- Evaluation should go in both directions
- Regularly evaluated
Culture is Evolving
Take findings and…
- Stay on top of trends
- Develop new ways to create a positive culture
- Find ways to drive satisfaction
- Solicit feedback from associates
- Identify creative ways to collect this information
Remember that culture should be developed by people who live it daily
Strategies to Improve Culture
Praise associates & share positivity
Be specific about what people do right
- Use Examples
- Associates take pride in a job well done
Empower employees to take on new roles
- Personal and team development
Provide clear structure
Focus on the quality of work performed
- Eliminate mistakes, waste, rework
Don’t wait to give praise or criticism
- Associate may not know he is doing something incorrectly
Integrating Culture - Store Level
How do we engage our staff?
- Break it down for each peer to easily understand
- Staff is more than just recent graduates
- Career pharmacists, hourly technicians, high & low performers, interns
Take a company message and make it relevant
- Highlight importance pieces
- Create short regular meetings
- 5 Minute Meetings / Daily Huddle
Lead by example
Integrating Culture – Corporate Level
Appropriate leaders to guide success
- Build teams and work with teams to bring success
Corporate training department
- Training specialists
- Human resources representatives
- Pharmacists
Management training/development classes
E-learning modules
- Good to disseminate basic information, but should NOT be used as a primary way to enhance engagement
Regular training classes (quarterly?)
Back to Pharmacy
Company culture is essentially the framework in which we operate to accomplish our goals
- Pharmacist goals
- Patient goals
- Employer goals
An established culture gives us directions and motivations
Allows team to have a driven focus toward an overall mission
Mission statement
Most mission statements will advance pharmacists from a traditional filling role into something more dynamic
Future Community Pharmacist
Knowledgeable about drug therapies
- Interchange of therapies
- Factor in the economics of therapy
Be an advocate
Work with new technologies
Accepting of more clinical role
Open to new initiatives and undertakings
Running an Effective Pharmacy Business
Key Performance Indicators (KPIs):
- measurable and quantifiable metric for tracking progress toward a goal
Customer service
Inventory management
Script and Sales Goals
Promised Times
Generic Utilization
Payroll/Staffing
Understanding third-party payments
Quality assurance
Compliance
Competencies Employers Look For
Communication
Teamwork
Productivity
Reliability
Ethical
Trustworthy
Compliant
Conflict Management
Accountability
Growth minded
Strategic skills
Leadership
Results-oriented
Interviewing Potential Candidates
Documents that may be needed:
- Resume
- Curriculum vitae (CV)
- Electronic portfolio
- Cover letter
- References
Discuss experience relative to the position
- Always use examples:
- STAR: Situation – Task – Action – Results
Education, certification, and technical requirements
Hiring managers are looking for someone who will:
- Compliment the current team and add value
- Want to grow in the organization
Criteria For Advancement
Experience
- Job history, residency completion, performance, certifications
Performance Appraisal
- From supervisor & Self-assessment
Customer satisfaction
- Survey patients through electronic surveys, comment cards, etc.
Containment of costs
- Profit-and-loss statement
Personnel management
- Encourage team leadership and interaction skills
- Show that you are interested in supporting the advancement of your peers in addition to yourself
Getting the Promotion
Stay Informed
- Subscribe to CDC or pharmacy times
- Job posting email alerts (example: Indeed)
Challenge Yourself
- Take on new roles or projects in the company outside of the normal role
Involvement in Pharmacy Organizations
Mentorship Opportunities
Management Classes
Specialty Certificate Programs
Keep Resume/CV Updated
Common Sense Pitfalls
Late for work or missing deadlines
Leaving the pharmacy a mess
Company dress code
Not mindful of inventory maintenance
Gossiping
Sharing personal information (including compensation)
Actual Practice Tips
Lead by example with a positive attitude
Maintain clinical knowledge
Interact with patients
Engagement in the community
Partner(s) Teamwork & Task Delegation
Take care of your technicians
Work with other departments in the store
Involvement in company programs
Attentive to recent communications
If you don’t know, ASK
Know your metrics and beat them
Make To-Do Lists
Recap monthly/quarterly significant
achievements
