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Pharmacy Technician Study Material

This is the second of a two-part series about a study conducted to establish and standardize preferred pharmacy practices at NAIC Homecare infusion pharmacy locations in the United States. Those practices were designed to improve staff performance, production (or compounding), and clinical and pharmacy materials management and to reduce the cost of labor and materials. Part I of this series addressed the methods (including data collection and data analysis) used to conduct the study. In this article, the results and conclusion of the study are presented.

Introduction

A "preferred practice" is an activity that improves the speed or efficiency with which a process is performed without compromising quality. At the time of this study, NMC Homecare was a national provider of the following services: home infusion pharmacy, intradialytic parenteral nutrition (IDPN) for dialysis clinics, home medical equipment (HME), and home health nursing services. There were 54 NMC Homecare pharmacies in 28 states.

Pharmacy practices were documented in four NMC Homecare locations that were selected according to patient volume and therapy mix, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey scores, and recommendations from regional pharmacy managers. A consulting team evaluated three primary areas of pharmacy: production (or compounding), clinical patient management, and pharmacy materials management.

Practices identified by the consulting team were reviewed by an NMC Homecare steering committee consisting of representatives from pharmacy, nursing, materials management, and corporate senior management. To prioritize the pharmacy practices and develop the implementation plan, each of the four practice locations was evaluated for compliance with the project objectives, the number of branches that could benefit from the implementation of preferred pharmacy practices, the estimated ease of that implementation, and the ability to document a reduced cost of labor and/or materials. The implementation plan included strategies for developing policies and communications and for ensuring the education of staff members, as well as methods of identifying branch-specific savings based on unique situations presented at some sites.

Data collected during the pilot study were used to validate existing productivity models and to develop new productivity and performance standards that were to be used to guide and monitor corporatewide pharmacy performance. The pilot study identified the possibility of an annual reduction of $296,000 in the cost of equipment, facilities, and processes. The average annual potential cost reduction was $5487 per site; 90% of that estimated reduction was the cost of labor.

Results of the Study

As noted above, data were collected from four NMC Homecare locations in the United States. Cycle times of the number of compounded orders (ie, the batches of units compounded) were calculated by observing the compounding activities performed for seven primary therapy types (Table 1). Data on hydration therapy, intraperitoneal nutrition (IPN) therapy, and treatment with erythropoietin, methylprednisolone, or desferoxamine were also collected. The term "compounding activities" was used to refer to all steps in the process after the receipt of the prescription to be compounded. Each of those activities had a defined start and stop time; therefore, time-and-motion studies were used to capture cycle times (Table 2). "Material relocation" is defined as the handling of work in process (ie, replacing source containers during an Automix compounding process).

The following variations in process were noted when data from the four NMC Homecare locations were evaluated:

* The use of a pump to compound antibiotics was infrequent (5 of 68 orders observed).

* Most of the antibiotic orders required reconstitution (45 of 68 orders observed).

* The use of a pump to compound antivirals was infrequent (5 of 16 orders observed).

* Variance in chemotherapy compounding time was significant and was due to the type of the device used (eg, cassette vs syringe).

An assessment of activity cycle times indicated that there was an opportunity to reduce cycle times by implementing improved processes for gathering supplies, checking pharmacists, and completing final paperwork. In addition, there was an opportunity to eliminate time associated with the relocation of materials by the appropriate use of Y-connectors in the automated total parenteral nutrition (TPN)/intradialytic parenteral nutrition (IDPN) compounding process. The time associated with the pharmacists' physically checking the Automix can be eliminated by using Baxter Multitask Operating Software (Baxter Healthcare Corporation, Deerfield, Illinois). That software allows compounding volumes and specific gravities to be input into an Automix control unit by a pharmacist who uses a computer terminal outside the cleanroom.

In every therapy, compounding represented the greatest time per order (50% to 80%). It was decided that improved compounding practices consisting of process improvement or using larger source containers, automation, or other technologies would have the greatest effect on reducing total production time.

In two sites evaluated, a work-sampling study was conducted to measure work allocation (the distribution of pharmacy staff time among the various pharmacy activities). That analysis provided information used to assess the following:

* The allocation of work effort. Was the work effort concentrated on value-added or nonvalue-added activities?

* The allocation of staff resources. Was work allocated to the most appropriate resources?

Figures 1 and 2 illustrate the percentage of total pharmacy staff time dedicated to primary activities. Those percentages indicated that there were two distinct types of operations: clinically-focused and distributive 1y-focused. Work allocation varied significantly for each type of operation (Table 3). In each model, pharmacy managers spent a significant portion of their time (46% to 77%) in day-to-day pharmacy management and clinical patient management. That amount was significant for branch managers who underestimated the amount of time that their pharmacy managers were required to contribute to daily patient management. In a distributively-focused facility, 51 % of the pharmacist's time was spent in compounding-related activities and 36% was spent in clinical patient management. The pharmacist's time allocation was reversed in a clinically-focused model: Fifty-five percent of the pharmacist's time was spent on clinical patient management and 34% on compounding-related activities. The allocation of time for tasks performed by pharmacy technicians was similar for both models; compounding-related activities performed by those staff members represented about 50% of their time.

Pharmacists are a relatively high-cost resource, and their activities can easily become constrained because of the proprietary clinical tasks that they must perform and the regulatory requirements to which they must adhere. NMC Homecare pharmacies, like most home infusion providers, have a clinical and distributive component. For some high-volume locations, it may be appropriate to allocate those functions to certain pharmacists instead of distributing the functions evenly among all the pharmacists. That allocation reduces interruptions during clinical tasks and improves efficiency of production. More efficient and economical resource allocation may be gained by appropriate work reallocation to patient representatives, admissions coordinators, and materials managers.

Pharmacy technicians are "flexible resources" who often perform compounding, materials management, and clerical tasks. The cross-utilization of technicians is economically advantageous. However, unless technicians are appropriately trained and skilled, certain branches of a corporation may not realize the potential cost savings that cross-utilization of staff can generate, so quality may be compromised.

Fifty-four branches participated in the impact assessment survey process described in this two-part series. The total savings was based on estimated labor and cost reductions in materials, including incremental costs. No savings was estimated if the branch reviewed was already practicing preferred behaviors. The average potential savings per branch was $5487 per year, and the annual savings opportunity at a single branch ranged from $658 to $47,494. Preferred practices were recommended only when they were feasible to implement and were cost-effective. The average number of preferred pharmacy practices identified per facility was five.

Labor represented 90% of the potential savings. Cost savings associated with work reallocation can be realized only when resources are constrained (ie, overtime) or variable (ie, hourly or per them staff). The cost saved was measured by estimating the time associated with the work activity and the differential resource cost. The average potential annual labor savings per branch was $2800 in pharmacist labor and $2150 in technician labor. Work reallocation can also result in the more appropriate assignment of tasks based on skill level. For example, reallocating a pharmacist's time spent on activities that could be conducted by a technician or other pharmacy staff member frees that pharmacist to perform higher value-added tasks.

Clinical and materials management processes (which have less distinct start and stop times and more frequent interruptions and are often performed by different staff members, depending on the site) are less discrete than the compounding of admixed products. In this study, it was therefore more difficult to identify discrete time savings attributable to specific systems or procedures. In general, productivity gains associated with the standardization of clinical management processes usually relate to process specifications (eg, documentation requirements, clinical monitoring requirements). At some sites evaluated in this study, improved materials management (eg, inventory monitoring and reordering systems) increased productivity and reduced operating costs (ie, having a national contract with a courier service). More significant gains in productivity may be achieved by the automation of tasks (eg, using a computerized order-entry system, automatic data transmittal of laboratory results). Process improvements should be focused on eliminating, reducing, or automating documentation steps or requirements and on developing systems to facilitate the access to and the exchange of information between staff and referral sources or patients.

Discussion

The results of this study provided the basis for establishing preferred pharmacy practices. The work activities fell into two categories: the compounding-distributive aspects of pharmaceutical care and communication-clinical-patient management. We identified in which of the offices the activities were more distributive or more clinical. That identification was made by comparing the amount of time devoted to compounding activities versus that devoted to clinical management. By evaluating the practices followed at the study sites, we developed standard procedures designed to enhance productivity at all locations.

Preferred practices fell into the following three categories: equipment related, facility related, and process related. The most easily identified opportunities for procedural change were found in the compounding process, because those steps were the most objective and the most controllable. Clinical management was always individualized to meet patients' needs and therefore could not be rigidly controlled. Although the time savings per unit compounded was small, the large number of units compounded at the sites studied yielded real savings. In some cases, common sense could have led to an easy process change. For example, in one office studied, the pharmacist would don proper cleanroom garb to enter the cleanroom to check Automix settings. However, the cleanroom layout was such that those settings could have been observed through the viewing window, thereby eliminating the need for gowning. Not having to gown would have saved time for both the pharmacist and the technician, as well as cost, because the expense of gowning would have been reduced. In other situations, reconfiguration of the compounding suite was required to improve the production workflow. One such case involved a cleanroom that was 20' x 20'; its perimeter was lined with hoods. The center of the cleanroom served as a warehouse for storing large-volume parenterals (LVPs), small-volume parenterals (SVPs), bags, and sets. The common practice involved the technicians' walking back and forth to select supplies all day rather than staging orders in an organized manner. Where equipment was needed, we performed a return-on-investment analysis to determine how long it would take for a radio frequency-weld tube sealer as opposed to metal ferrules to pay for itself. It was determined that the cost would have been recouped in 6 to 8 months in one office but that the investment was not justified in another office.

As the study progressed, some of the process improvements were implemented on the spot. That occurred when the process change was location specific and did not require a capital expenditure as in the Automix-setting case cited above. Process changes requiring capital were presented to senior management for approval, and process changes requiring senior management directive or a change in policy statement were referred to the appropriate director or vice president. Proposed policy changes were validated to maintain the corporate goal of compliance with pharmacy law, standards of practice, and the standards of the JCAHO. Policy changes were formalized and implemented at the field level, where any necessary equipment purchasing and attendant training were carried out.

The final step in the process was to implement a productivity measurement tool. By writing a software routine used to calculate the average time required to complete a specific task and multiplying the number of times that task occurred during a given time frame, an expected number of full-time equivalents were predicted. That information was used to guide staffing decisions and served as a mechanism that the pharmacy manager could use to identify areas in which additional training was needed.

Conclusion

Documentable, quantifiable cost savings can be achieved by identifying and implementing preferred pharmacy practices in multifacility home infusion providers like NMC Homecare. Those processes provide an ideal opportunity for a consultant to work with an infusion product and service provider. Independent consultants offer a fresh perspective, the ability to focus totally on observation and analysis, a potentially broader base of experience with which to compare the practices of other similar organizations, and experience in operational analysis.

Leveraging the resources of each partner results in reducing the overall cost of providing health care. The consultant recommends change, the company management provides encouragement and support, and the field staff execute the change. Each of those elements is essential to an organization that challenges the status quo and improves its process.

The process flow analysis techniques used in this study were unobtrusive during the day-to-day operation of the pharmacy. Information gathered allowed NMC Homecare to reduce the cost of business, which was reflected by a decrease in overtime and the use of per them staff.

In the current climate of downward pressure on reimbursement for the products and services of managed care organizations and other payers, providers of home infusion therapies must continually look for ways in which to streamline their operational processes. An analysis of process flow and the discovery of preferred practices provide the framework for change.

Stanley N. Chamallas, BS, RPh, FASHP

Tandem Medical, Inc

Greenland, New Hampshire

Kathleen Sullivan, BS, MBA, RPh

BD Medical Systems

Address correspondence to: Stanley N. Chamallas, BS, RPh, FASHP, Director of Clinical Affairs, Tandem Medical Inc, 6 Bayridge Road, Greenland, NH 03840. E-mail: schamallas@ tanmed.com

Copyright International Journal of Pharmaceutical Compounding Jan/Feb 2003
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