Developing a service excellence system for ambulatory care pharmacy services.

A service excellence system for ambulatory care pharmacy services is described. An interview was designed to measure the needs, expectations, and priorities of a random sample of ambulatory care patients at a 964-bed county teaching hospital and its clinics to determine trends in patient service and satisfaction. The interviews were conducted by the same interviewers with the same script, and follow-up was continuous for two years. Information was summarized for each question and pharmacy site. In defining "service excellence" from a patient's perspective, it was determined that patients wanted a continuation of low-cost prescriptions, decreased waiting time, a friendlier, more caring staff, and environmental modifications. A service excellence system with key performance indicators was then designed and implemented. This effort included recruiting employees with behaviors that support service excellence, training employees to deliver service excellence, creating an environment that promotes patient satisfaction, and designing an ongoing monitoring system. Next, it was imperative to change the attitudes of staff and existing processes to meet or exceed patients' expectations. This phase addressed such issues as patient waiting time, staff-patient interaction, patients' environmental concerns, and staff ideas for service improvement. Finally, changes in service levels were measured. Overall patient satisfaction increased from 72% to 93% at the maincampus pharmacies. Satisfaction at the smaller sites rose from 85% to 95%, while turnaround time and number of pharmacist full-time-equivalents remained stable. A service excellence program was effective in addressing the service issues of ambulatory care patients at a large teaching hospital.

Formulary and economic considerations in the selection of antiplatelet agents.

A pharmacoeconomic model for evaluating antiplatelet therapies is described. In order to conduct a pharmacoeconomic analysis, it is important to understand the course of the disease under study and the prevention and treatment options, identify the associated economic consequences, develop concomitant strategies, and target high-yield decisions. The steps of a pharmacoeconomics-based decision are defining the pharmacoeconomic problem, creating a cross-functional team, determining the study's perspective, determining the treatment alternatives and outcomes, selecting the appropriate pharmacoeconomic method, placing a monetary value on outcomes, identifying resources and data sources, establishing probabilities of outcomes, using decision analysis, undertaking a cost or sensitivity analysis, presenting the results, developing and implementing a policy or clinical intervention based on the results, educating health care professionals about the new policy or intervention, and documenting the quality of care and potential cost savings through follow-up. Clopidogrel is given as an example. The composite endpoint of myocardial infarction, stroke, or vascular death has been shown to be 8.7% lower with clopidogrel than with aspirin in patients with recent myocardial infarction, recent ischemic stroke, or symptomatic peripheral arterial disease. Clopidogrel costs more than aspirin but may be considered as first-line therapy for high-risk patients, patients who are allergic to aspirin, or patients who cannot tolerate the gastrointestinal effects of aspirin. Cost-effectiveness analyses can be used to support formulary decisions about which antiplatelet agent should be used; the use of a particular agent ultimately also depends on efficacy, safety, pharmacodynamics, patient-specific factors, and relative direct and indirect costs.

Designing a disease management program: how to get started.

To successfully design and implement disease management programs, clinicians must understand the disease's natural course and cost drivers, base the diagnosis and treatment on the disease process and not the reimbursement schedules, educate and reinforce compliance to improve treatment outcomes, and focus on commonly occurring and costly chronic diseases. This article describes a 7-step process for developing a disease management program based on those concepts. The changing role and functions of the P & T Committee in disease management programs are also presented.

How to develop a proactive formulary system.

To develop a quality formulary system, a proactive approach is necessary. This approach incorporates a prospective product and concurrent product analyses. A prospective product analysis, in turn, involves a review of current formulary agents, those likely to enter the marketplace shortly, and the formation of an expert review panel. This panel's tasks are to examine therapeutic, economic, and humanistic aspects of therapy and to set initial parameters for appropriate and cost-effective use of accepted products. Keys to a successful formulary system are to continuously monitor drug use and compliance with criteria and to work collaboratively with all institutional professionals in the development, implementation, and monitoring of the system.

Multidisciplinary task force for controlling drug expenses.

The establishment of a multidisciplinary task force to control increasing drug costs is described. From 1986 to 1992, dollars spent on drugs at a 964-bed teaching hospital increased from $9.8 million to $26.8 million, despite a tightly controlled formulary, prudent purchasing practices, prescribing restrictions, an antimicrobial order form program, a target-drug program, and an active pharmacy-run cost intervention program. These increases occurred as a result of changes in the mix of drugs prescribed, increases in outpatient volume, inflation, and price increases resulting from the Omnibus Budget Reconciliation Act of 1990. A multidisciplinary task force composed of seven teams--AIDS and related issues, ambulatory care, medicine, obstetrics and gynecology, pediatrics, surgery, and systems and procedures--was formed to identify ways to reduce drug expenses and enhance revenue. Each team made recommendations designed to reduce the rate of growth of pharmaceutical expenses. To implement these recommendations, the task force used a variety of verbal and written strategies to educate and communicate with physicians, pharmacists, nurses, pharmaceutical company representatives, and patients. A system was developed so that goal achievement could be monitored. The program, which was implemented on September 16, 1991, and continued through September 30, 1992, reduced the growth in drug expense by $2.33 million. As a result of the program, control of the drug expenses became an institutional priority, not merely a pharmacy department priority. By establishing a multidisciplinary team approach involving physicians, administrators, nurses, and pharmacists, a substantial reduction in the growth of drug expenses can be achieved.

How to use structured decision making in developing therapeutic, cost-effective formulary systems.

The formulary decision-making process must evolve from a system which places a greater emphasis on the financial factors to one which includes therapeutic and patient outcomes. Ideally, all available options and possible consequences of a decision--economic as well as clinical--should be examined by P & T Committees. In this article, three methods to assist in formulary selection and management activities are described: the inventory management approach, the cost accounting approach, and the criteria-based protocol approach. All three methods have a place in the overall development and management of an effective therapeutic formulary system.

A pharmaceutical care challenge: recruiting, training, and retaining pharmaceutical care practitioners.

We do not claim to have all the answers when it comes to implementing an ideal pharmaceutical care model. We are not even sure what all the characteristics of such a model should be. We have recognized, based on our interpretation of the model, that meeting the demands of pharmaceutical care will require changes and advanced skills in our staff. We continue to work in creating an environment where the concept of pharmaceutical care can flourish. Our department has focused on defining and then providing pharmaceutical care through individual practitioners and patient care teams. More employee empowerment with less management control was the key to facilitating initial phases in our pharmaceutical care model. A successful orientation process has further enhanced our abilities to hire new graduates and/or experienced practitioners for our open positions. We believe we have taken some significant first steps toward recruiting, training, and developing our staff to become competent and satisfied with their newly developing role as pharmaceutical care practitioners.

Current treatment of gram-positive infections: focus on efficacy, safety, and cost minimalization analysis of teicoplanin.

The current health care environment has had a significant impact on hospital Pharmacy and Therapeutics Committee formulary decisions. In evaluating a new therapy for formulary inclusion, a cost savings along with equivalent or an improvement in patient care and safety is optimal. Teicoplanin is an investigational glycopeptide antimicrobial agent with a spectrum of activity similar to vancomycin. Unlike vancomycin, however, teicoplanin has a long elimination half-life permitting administration once daily, and is well tolerated when given intramuscularly. In addition, teicoplanin is associated with a favorable safety profile. Red man syndrome does not appear to be a significant clinical problem. Results of our cost minimalization analysis using the average acquisition costs of vancomycin revealed that teicoplanin (400 mg), at an average acquisition cost of less than $28.46 when administered intravenously and $30.93 when administered intramuscularly, offers a clinically efficacious, safe, and less expensive alternative to vancomycin therapy.

Legal and medical issues in therapeutic interchange: implications for pharmacists, physicians, and P & T committees.

In today's health care environment, pharmacists, physicians, P & T Committees, hospital administrators and other clinicians involved in therapeutic interchange issues should be knowledgeable about the legal and medical issues associated with this practice. In this paper, a general discussion of liability under tort law is provided, followed by a specific discussion of the legal aspects of therapeutic interchange. In addition, steps that hospitals, P & T Committees, physicians, and pharmacists can take to establish sound therapeutic interchange policies--and thus reduce liability risks--are presented. Armed with this knowledge, clinicians and administrators can continue to provide cost-effective, patient-oriented care that uphold their professional responsibilities.

Projected cost savings associated with cefmetazole: a new cephamycin for the hospitalized patient.

In this article, a cost-minimization model was used to make an economic comparison between cefmetazole and cefoxitin--two drugs with comparable in vitro spectra of activity, clinical efficacy, and safety profiles. Drug acquisition costs were estimated from published information and labor and material costs were calculated based on actual costs at Presbyterian Hospital of Dallas. Costs of the agents were calculated based on the dosage and administration schedules typically used in published clinical trials of cefmetazole and cefoxitin and on the typical dosing patterns of cefoxitin used at Presbyterian Hospital. Results of the cost analysis revealed that an annual savings of $36,015 to $59,143 could be realized at Presbyterian Hospital if cefmetazole were used in place of cefoxitin for surgical prophylaxis. Furthermore, use of cefmetazole in place of cefoxitin for wound treatment would yield annual savings of $33,242.

The use of a decision analysis model in multidisciplinary decision making.

This paper describes a conceptual decision analysis model for use in multidisciplinary decision making. Decision analysis was used to structure a decision process that ensured the best choice through consensus building among hospital decision makers. The four basic steps of the decision analysis model included: (1) identifying and establishing boundaries of the decision problem; (2) structuring the decision problem; (3) characterizing information needed to fill in the structure; and (4) choosing a preferred course of action. The selection of the best intermittent intravenous drug delivery system for Presbyterian Hospital illustrates the application of the conceptual model. This type of decision analysis model becomes a useful consensus building and communication device for the administrative pharmacist who is involved in multidisciplinary decision-making processes.

Communications at the pharmacy-nursing interface.

The next evolutionary step at the pharmacy-nursing interface is the implementation of a new patient care delivery model to enhance quality and contain costs. In addition, increasingly sophisticated biotechnology drugs and drug delivery systems will require close communication and collaborative practice between pharmacy and nursing. The effective communication interface already established will form the foundation for an even closer relationship and for working together effectively and efficiently in the constantly evolving health care environment. Indeed, regardless of what the future may hold, effective communications and resultant teamwork will continue to strengthen the achievement of patient care goals and ensure a bright future for both departments.