Management I FINAL
Right Product
"If it is not on the shelf you can't sell it!" 10,000+ prescription items Usage reports Pharmacy Location New products New generics PBM and Hospital Formularies New start pharmacy - industry data, wholesaler
Defining Quality in Health Care 1. IOM
"the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge"
2. CMS
"the right care for the right person every time"
Value-Driven Health Care
Health care that is selected based upon relative value to other alternatives, not just on quality.
Structure --> Process --> Outcome Examples
Medication profile --> review profile --> no ADEs Pharmacist --> counseling --> adherence/drug effectiveness Warfarin Clinic --> dosage monitoring --> no bleeding events
3. Outcome
Pt coming in for heart attack, what kind of outcomes do they need to have to be discharged?
PURCHASING AND INVENTORY CONTROL Why is inventory and purchasing important?
Purchasing right and managing inventory are the two of the greatest factors in determining the profitability of any business.
Quality versus Value
Quality: what you get Cost: what you pay Value: quality/cost
Improve Safety of High-Risk Medications
The Beers Criteria The STOPP (Screening Tool of Older People's Potentially Inappropriate Prescriptions)
Buy Low/Sell High
This is how a business makes money. Purchasing and inventory is critical to success -sell side is harder to effect in pharmacy -must but right to insure profits
If I make no error when I dispense medications, is it good enough? NOOOOOO!!!! think QUALITY think COST think VALUE
Value driven health care -about quality of patients care. -cost of care should not be high = cost effective.
Verbal Orders
Verbal orders for medications should only be taken in an emergent situation. Telephone orders for medications should always be read back to the prescriber AFTER the order has been transcribed to paper. When reading back orders verify numbers. -15 could be mistaken for 50
Basic Safety Principles: 1. Automate
Warfarin dose -Automated RX system doesn't let them add med without confirming
Preventable ADEs
-Caused by medication errors -If you did not have the error the patient would not experience the ADE EXs: 1. Over-anticoagulation associated with overdoses of warfarin and heparin due to insufficient monitoring. 2. Oversedation and respiratory depression associated with overdoses and drug- drug interactions of opiate agonists or benzodiazepines. 3. Hypoglycemia associated with insulin overdoses. 4. A miscarriage due to a wrong med was dispensed. Instead of Materna, the patient received Matulane (a chemotherapy drug used to treat Hodgkin's disease). 5. Hospitalization due to a wrong med was dispensed. A 7-yo boy received Toprol XL instead of Tegretol-XR.
Inventory Turns
-In accounting, the Inventory turnover is a measure of the number of times inventory is sold or used in a time period such as a year. -Turnover=COGS/average inventory CALCULATE: -Average monthly COGS is $600,000.00 -Average inventory is $450,000.00 -Annual COGS 600,000 x 12 = 7,200,000.00 Turnover is 7,200,000.00/450,000.00 = 16
Value-driven health care environment
-Measuring quality and price (VALUE) of care -Publishing quality and price (VALUE) of care -Effective use of health information technology -Creating positive incentives for high-quality, efficient health care. *lower star rating = can not enroll patients
Pharmacy Quality Alliance (PQA)
-Modeled, for the most part, after other healthcare alliances -Current members include pharmacy associations, government agencies, pharmaceutical companies, employers, health plans, PBMs, and others
IOM Report
-More than 1.5 million people are injured each year by medication errors. -Hospital care: 380,000-450,000 preventable adverse drug events (ADEs) -Long-term care: 800,000 preventable ADEs -Ambulatory care: 530,000 preventable ADEs
Nurse's 6 Rights
-Patient -Drug -Dose -Route -Time -Result
NCQA
-Reviews and accredits managed health care organizations (voluntary) -Develops quality standards and measures that are applicable across organizations -HEDIS (Healthcare Effectiveness Data and Information Set) -immunization rates among employees - Smoking cessation counseling -Annual performance reports identify opportunities for improvement (Measure info and publish it so employers can look at the plans and decide who to contract with. Critical for plans to be a better job in their quality.)
Layout Design Considerations
-higher utilization of space, equipment, and people -improved flow of information, materials, or people -improved employee morale and safer working conditions -Improved patient/client interactions and safety -flexibility In either hospital or retail need these things.
The holes in the swiss cheese that can lead to an ADR
-prescriber's knowledge -computer screening -pharmacist's knowledge -patient risk factors -pharmacogenetics -drug admin -patient education -monitoring
What is the goal of pharmacists activities in the medication use system?
1. Safety (free from harm) 2. Efficacy (get desired outcome) Things that can prevent this: medication errors, adverse drug events.
Preventable ADE
ADE that were due to error or should have been prevented by existing mechanism
System Factors Leading to Errors
1. Complexity - too many people behind the counter 2. Workload - too low (too little to do) or too high (too much to do, can't focus) 3. Poor design- the physical layout, inefficiency in computer system 4. Interruptions and distraction- lots of people, phone ringing, counting. Takes focus away. EX: Big cause in aviation studies 5. Culture- never learn from mistake and they keep occurring
3 types of stock
1. Cycle Stock -regular stock 2. bufferer or safety stock - additional stock in case of demand or supply issues (Top Movers) 3. Speculative or anticipatory Stock - stock kept on hand because of future demand or expect price increase
Organizations Involved in Measuring Health Care Quality
1. Joint Commission =Certify different organizations (such as hospitals). Have to be accredited. 2. National Committee for Quality Assurance (NCQA) 3. Pharmacy Quality Alliance (PQA) 4. CMS
The Medication Use Process in Ambulatory Care:
1. Ordering the PX 2. Routing the RX 3. Entering the RX 4. Dispensing the RX 5. Administering the RX 6. Counseling the patient about the RX 7. Monitoring the patient
What are the INPUTS needed to start a system?
1. Patient (with a problem) 2. Drugs, access to providers 3. A location
Define activities performed in each step of the Medication Use Process
1. Prescribing 2. Transcribing/Documenting 3. Dispensing 4. Administering 5. Monitoring
IOM's quality dimensions
1. Safe -no harm to the pt 2. Effective -treat the pts condition 3. Patient-centered (or personalized) -care according to pts needs 4. timely -problem with the VA system 5. efficient -doctors should not order unnecessary lab tests 6. Equitable -pts should receive some level of care despite age, sex, ethnicity
High-Level Portrayal of a Medication Use System
1. Selecting and Procuring -est formulary 2. Prescribing -Access patient, determine need for drug therapy, select and order drug 3. Preparing and dispensing -Purchase and store drugs, review and confirm order, prepare meds, distribute to patient location 4. Admin -Review dispensed drug order, assess patient and administer 5. Monitoring -Access patient response to drug, report reactions and medication errors
Reporting Medication Errors
1. The Food and Drug Administration 2. Vaccine Adverse Events Reporting System 3. Institute for Safe Medication Practices -Consumers -Health care professionals -Vaccine errors -Medication errors
Quality problems classified
1. Under use -adult and childhood immunizations, inhaled corticosteroids for asthmatics, and detection and treatment of HTN 2. Overuse -sedatives, hypnotics, antidepressants, and antipsychotics use in elderly, pain meds 3. Misuse -avoidable complications due to polypharmacy
Picking the right vendor can be steered by:
1. Your buying group- normally has a preferred wholesaler 2. Pricing offered- watch for deceptive deals 3. terms offered and discount 4. reputation 5. big 3 are ABC, McKesson, and Cardinal but there are others 6. services...
5 helpful ideas for a community pharmacy layout
1. locate high-draw items around the periphery of the store -more time I spend in the store the more likely I am to but 2. Use prominent locations for high-impulse and high-margin items - candy and magazines in the front 3. Distribute power items to both sides of an aisle and disperse them to increase viewing of other items 4. Use end-aisle locations 5. convey mission of store throughout careful positioning of lead-off department
Cash Discounts
2/10 versus net 30 EFTs
Which of the following is an action-based error? A. Writing Klonopin but meaning clonidine B. Putting 40 meq of potassium chloride into a bag which is supposed to have 20 meq C. Knowing that a patient had a previous reaction of hyponatremia to hydrochlorothiazide and not remembering it D. Giving trimethoprim/sulfamethoxazole to a patient taking tikosyn, which is contraindicated
A Good plan, bad education
What is a system?
A collection of processes and mechanisms that flow between each other to accomplish an end. A circle between: -clinicians/admin -Prescribers -Pharmacists -Nurses -patients/care givers
Changing Systems
A system is a group of items, events, or actions in which no item, event, or action occurs independently. Understanding the relationship among the various subsystems is an integral part of the study of organizational change.
Medication Errors leading to ADEs example
An older patient with rheumatoid arthritis died after receiving an overdose of methotrexate--a 10-milligram daily dose of the drug rather than the intended 10-milligram weekly dose. Some dosing mix-ups have occurred because daily dosing of methotrexate is typically used to treat people with cancer, while low weekly doses of the drug have been prescribed for other conditions, such as arthritis, asthma, and inflammatory bowel disease.
2. Process
Any phase of the medication use process -tech entering medication -checking orders -filling meds
Case - What would you do? Ms. Y, a 63 yo woman, visits Bob's pharmacy to indicate she has seen her physician who renewed her five prescriptions for her chronic conditions. Medications Quantity ordered Calan (verapamil) SR 240 mg po qd # 90 Lasix (furosemide) 40 mg po qd # 90 Coumadin (warfarin) 4 mg po qd # 90 Colace (docusate) 100 mg po bid # 180 K Dur (potassium) 10 meq po bid # 180 Bob notes that the medications and directions are the same as for her last fill, so he fills her medication, places the bottles in a prescription bag and staples the bag shut. When he dispenses the medication, he simply hands Ms. Y the bag, completes the financial transaction for her co-pays and wishes her a good day. Later that day, Ms. Y came back to the pharmacy and asks to speak with Bob personally. Ms. Y is upset. She noticed that her blood thinner was a different color from the last time she had it filled. Bob realized that he filled her warfarin with the wrong strength (5mg instead of 4mg). What would you do if you were Bob?
Apologize and ask if she has taken any yet. Label the shelf. Show and Tell- Show the patient the pill and tell them how to take it. So she will know if they look different. Key to Success: -Blame free culture- should feel free to bring mistake forward and report the mistake.
2. Standardize
As a hospital/pharmacy was are going to do things a certain way EX Emily Jerral
Standardization
Avoid abbreviations AT ALL. Spell out "units" Standardize and limit drug concentrations -Limit options for physicians and options to select from to reduce errors
Thinking Error
Bad plan, great execution Action is as planned a. Rule-based mistake -used rule incorrectly b. knowledge based mistake -you were suppost to know something EX: Above 25 mg HCTZ isn't effective but give pt a 50 mg dose EX: Lapse- forgot patient had an allergy and give them med they are allergic to.
Which of the following is a knowledge-based error? A. Writing Klonopin but meaning clonidine B. Putting 40 meq of potassium chloride into a bag which is supposed to have 20 meq C. Knowing that a patient had a previous reaction of hyponatremia to hydrochlorothiazide and not remembering it D. Giving trimethoprim/sulfamethoxazole to a patient taking tikosyn which is contraindicated
C
4. Reduce steps and handoffs
COMPLEXITY- techs double count before checking (adds potential for error)
A good inventory clerk is critical to a successful business. This person is dedicated to:
Checking order correctness Looking for product damage Looking for off contract purchasing Rotating stock Watching for price changes Verifying stock dating
Root-Cause Analysis
EX: Emily Jerral Case 1. Root Cause = indented the single event that lead to the bad outcome EX: improper IV prep with sodium chloride 2. Proximal Cause = the last step before the negative event happened EX: was not checked properly Success in the route cause analysis is founded on the belief that humans make mistakes and errors are inevitable, but that organization's improvement is always possible and the ever present goal. EX: Airline industry. Pilots make mistakes so lets make a system to prevent as much as we can
The "Swiss Cheese Model"
Each slice = protection Hole = active failure (something we commit that we can not anticipate and is short lived) EX: picking the wrong drug off the shelf. Latent conditions- designed into medication use that can create errors and get all the way to the patient. Designed into the system so every patient could be effected by the design flaw EX: system does not flag DI with Warfarin. Latent b/c sitting there until the opportunity presents itself. The user didn't do anything wrong. It was the system EX: too many techs. Designed into the system (schedule). Waiting for problem to occur. Too much complexity --> error GOAL: 1. Prevent hole 2. Line up protection mechanism to prevent holes from getting through
Right Vendor
Every pharmacy has at least one wholesaler, many times there are multiple suppliers for a pharmacy. Chain stores use their warehouses but also use a Wholesaler or even another secondary or tertiary vendor.
B. To improve the effectiveness of communication among health care providers
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
Other suppliers
Generic houses Specialty vendors Direct from manufacturer (hospital) Peer to peer including locally or MatchRX
Serial Discounts
Getting multiple discounts together like dating and cash discounts.
Action Based Error
Good plan, Bad execution Do things and carry out plan wrong a. action based slip -technical b. memory-based lapse -Did not have necessary knowledge
What are Examples of System-Level Initiatives in Health Care and Pharmacy Practice to Minimize Medication Errors? 1. System-Level Initiatives
How to improve the accuracy of patient identification How to improve the effectiveness of communication among health care providers How to improve the safety of using medications
PQA Mission
Improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist levels; collecting data in the least burdensome way; and REPORTING MEANINGFUL INFORMATION TO CONSUMERS pharmacists, employers, health insurance plans, and other health care decision-makers to help make informed choices, IMPROVE OUTCOMES AND STIMULATE THE DEVELOPMENT OF NEW PAYMENT MODELS.
Why is understanding system-level change important?
Individual-level change is crucial but may not be sufficient. System-level change is necessary. -It is important to acknowledges the complexity of the practice. -Organizational change is a good example of system-level change.
Why is inventory important?
Inventory usually represents a pharmacy's largest asset. The cost of inventory in our current environment is increasing and requires even a more watchful eye. Cash Flow.
Inventory Management
Is defined as the practice of planning, organizing, and controlling inventory so that it contributes to the profitability of the business.
What date is inventory of controlled substances required?
January 15th
The power of Buying Groups and Co ops
Lowering cost with manufacturer rebates Tiered discounts Contract purchasing
Quantity Discounts
Not always the best option because of carrying cost and opportunity costs, but consideration should be given to it. -Carrying costs can include warehousing, damage, obsolescence which includes potential out of date issues, newer products, and less demands. -Opportunity costs include loss of resources for purchasing other items. Cash Flow issues. Group Purchasing Organizations (GPOs) and Buying Groups such Cooperatives.
3. Checklists
Nurses use mentally. Check to make sure do right thing each time.
What are some PROCESSES?
Occurrences that happen from receipt to patient EXs: RX to pharmacist, imputed, filled (by someone or a robot), checking
Balance between procurement costs and carrying costs vs. stock out costs and opportunity costs
Procurement costs include cost of purchasing, inventorying, receiving, and stocking Carrying costs include costs of storing, damage and obsolescence Stock out costs include cost of lost sale, lost customers, expedited fees, and freight costs Opportunity costs include cost of loss of revenues towards other opportunities
Wholesaler Services
PSAO (pharmacy services administration organization) Delivery time/days Value offered services Full line of items in stock Private Label Programs Drug Pedigrees Technology Drug Returns
Non Preventable ADEs
Patient allergy
5. Redundancy
Pharmacist double checks meds before leave pharmacy
Resources to help with Quantity
Pharmacy Usage Reports/Customer History Perpetual inventory Stock control services Reverse Distributors
Dating Discounts
Prepay, quicker pay, basis points COD Delayed/future dating Wholesalers entice buyers with dating, but taking the quick discounts is much better option. -Exception might be a new start pharmacy with cash flow issues
Look-a-like/Sound-a-like Drugs
Review how drug is displayed in computer system. If doses are similar will it be easily confused? Review storage of the medications. May need to separate and use alerts. Use tall-man letters -doPAMine and doBUTamine -vinBLAStine and vinCRIStine
4 Objectives of purchasing "right"
Right product Right price Right quantity Right vendor
C. To improve the safety of using medications
Standardize and limit the number of drug concentrations used by the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
Measuring Quality in Health Care: S-P-O Framework 1. Structure
Stuff you can touch -number of pharmacists/techs -credentials -licensing -reference books -counseling facilities -facilities
Components of the Organizational Pyramid
Tasks Personnel Technology- automated phone calls. Resources Patients Culture Organizational structure Goals
Technology and Inventory Management
Technology can assist in inventory management. Kirby Lester, Eyecons and other robotic machinery can aid in getting accurate counts as well as insuring the proper product is being counted. -Pharmacy Software with perpetual inventory -EDI ordering through FTP -Stock out updates -Price updates -POS reordering based on sales -CSOS ordering for C2 drugs
Right Price
Terms -negotiating a great price WAC minus -Generic Pricing- not the same everywhere -Rebates - generic drugs -Discounts- quantity, cash, dating, serial
QUALITY MANAGEMENT Institute of Medicine (IOM)
The frequency of medication errors and preventable adverse drug events (ADEs) is a very serious cause for concern Medication error= any error occurring in the medication-use process EX: dispensing wrong med or dose Adverse drug event= any injury due to medication
What Would You Do? A pregnant patient was prescribed Diclectin®, but Dicetel® was filled. The patient had been on Dicetel® many times in the past.
The names are very similar. Confirmation Bias- cant read prescription and see drug on patients profile and assume it is the same medication. Correct this by: -Call the prescriber. -As the patient what the medication is for. -Talking with the patient becomes very helpful.
Strategic Importance of Layout Decisions
The objective of layout strategy is to develop an economic layout that will meet the pharmacy's business and professional requirements Acute Vs Ambulatory
What are some OUTPUTS?
The outcome for the patient, more or less EX: filled RX
Workflow
The path of systems used in the linked flow of actions with a specific start and finish that describe a process
Define the challenges in today's pharmacy environment:
Today's Reality 1. too many prescriptions 2. More dynamic role in patient care 3. Insurance expect and help desk 4. too much information 5. too little time
The Yerkes-Dodson Curve
Under stimulation -boredom -fatigue - frustation -dissatisfaction Optimum Stimulation -creativity -rational problem-solving -progress -change -satisfaction =THE ZONE Over stimulation -ineffectual problem solving -Exhaustion -Illness -low self-esteem EX stress level on exams
A. To improve the accuracy of patient identification
Use at least two patient identifiers when providing care, treatment or services. -Name -Birth Date Bar coding
Stroop Test featuring Jham
You can say words faster than you can say cololrs -Hard to say a color when it doesn't match the word -We are human. We have limitations. We can not overcome out limitations. We make errors.
Right Quantity
You need a Balance -Too little causes loss of sales, potential loss of customer -Too much causes loss of resources, cash flow problems
Organizational change is...
a fundamental reorientation in the way an organization operates
An organization is...
a group of individuals working to reach some common goal
CHANGE MANAGEMENT Change is...
a relational difference between states; especially between states before and after some event
Medication Error
an event that leads to inappropriate medication use
Medications that account for 50% of ED visits for ADEs in Medicare patients
antidiabetic agents (e.g., insulin), oral anticoagulants (e.g., warfarin), and antiplatelet agents (such as aspirin and clopidogrel).
2. Periodic method
count and evaluate stock levels at certain intervals
Potential ADE
error that can lead to an ADR but for some reason did not
Physical Inventory is important to...
maintain accurate financial records
Adverse Drug Event
the actual negative experience that the patient has as a result of the medication error
3 Methods of Inventory Management 1. Visual method
time consuming method of looking at each stock item for ordering and inventory
3. Perpetual method
using technology to keep a running inventory total
