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.

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.

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.

Marketing an investigational drug service.

The customer survey was a useful tool for marketing the IDS. It provided guidelines for making decisions about the best use of limited human and material resources. Analyzing the results of the survey provided new priorities and directions for the IDS. These results were then used in conjunction with pharmacy financial and operational data to focus on areas of greatest importance to the customers and the pharmacy. Physicians should not be reluctant to pursue compassionate use treatments because of the administrative programs responsibilities that accompany such programs. Every patient should have the opportunity to benefit from alternative therapies that are investigational. For the quality of patient care to be maintained or even enhanced when studies are conducted, nurses must be well trained. The marketing survey fulfilled its purpose of identifying service gaps and allowing us to improve our services.

Microcomputer-assisted monitoring of medication-dispensing errors.

A microcomputer-based program for collecting and monitoring data on medication-dispensing errors made by pharmacy personnel is described, along with the policies and procedures for dealing with the responsible employees. The program was implemented at a 964-bed teaching hospital. When a medication-dispensing error is suspected, the director of pharmacy initiates a medication discrepancy follow-up report form. The appropriate supervisor fully investigates the incident, completes the form, and returns it to the director, who assigns a point value to the error on the basis of whether it injured or had the potential to injure the patient. Information from the report is then entered into an automated file. Data are sorted by the computer, allowing the performances of pharmacy personnel to be monitored. Progressive educational or disciplinary actions are taken depending on the number of points accumulated annually. Responsibility for an error is not assigned unless there is absolutely no question as to its origin, and dispensing-error points are not carried over from year to year. Since the program was implemented more than three years ago, the average number of reported medication-dispensing errors has decreased from 20 to 6 per month. Departmental procedures for monitoring and analyzing dispensing errors and for initiating disciplinary actions against personnel who commit many dispensing errors have been successful in creating greater awareness of the need to prevent such errors and in reducing their number.

Controlling cephalosporin and aminoglycoside costs through pharmacy and therapeutics committee restrictions.

The cost-reducing effect of antibiotic restrictions imposed by a pharmacy and therapeutics (P & T) committee was evaluated. The pharmacy department developed guidelines restricting the use of second-generation cephalosporins and aminoglycosides in cooperation with the infectious disease division. The P & T committee approved the restrictions, and the pharmacy department disseminated information on the program to the hospital's physicians. Specific indications were developed for the use of amikacin, tobramycin, cefoxitin, and cefamandole. In order to prescribe a restricted antibiotic, physicians are required to write an approved indication on the physician's order form. Residents cannot prescribe restricted antibiotics for unapproved indications unless they acquire the signature of an attending physician. Pharmacy personnel closely monitor the restricted antibiotic use and enforce the established guidelines. The major impact of the restrictions was the reversal of a previous trend toward the use of more expensive second-generation cephalosporins and tobramycin to the use of first-generation cephalosporins and gentamicin. Injectable antibiotic expenses decreased by $193,172 in the first 12 months of the program. Antibiotic restrictions imposed by the P & T committee were effective in reducing the cost of antimicrobial therapy.

Establishment and operation of an oncology satellite pharmacy.

The justification, establishment, and operation of an oncology satellite pharmacy in a 545-bed university teaching hospital are described. The oncology satellite pharmacy was established because of concerns expressed by nurses about the potential health hazards of handling cytotoxic drug products. The satellite pharmacy, which is located near the three floors that serve the majority of the adult and pediatric oncology inpatients, is responsible for preparing all injectable cytotoxic drug products used in the institution; this includes inpatient and outpatient use. The satellite is staffed by one full-time equivalent (FTE) supervisor, two FTE staff pharmacists, and 1.4 FTE technicians. It is open nine hours a day during the week and four hours a day on weekends. Pharmacists working in the satellite prepare all cytotoxic drug products in a laminar-flow biological safety cabinet. The pharmacists also provide clinical services for oncology patients, such as monitoring drug therapy and providing drug information to patients, nurses, and physicians. The implementation of an oncology satellite has allowed this pharmacy department to expand its services and decrease the potential risks to personnel involved in preparing and administering cytotoxic drug products.

Involvement of a state society of hospital pharmacists in third-party reimbursement for nondistributive services.

The investigation by a state society of hospital pharmacists of the possibilities for third-party reimbursement for nondistributive services is described. A questionnaire was sent to all hospitals in the state to determine what nondistributive services were being performed that might qualify for third-party reimbursement. A committee was established to investigate what nondistributive services were being reimbursed separately and which nondistributive services had reimbursement potential, and to establish guidelines that hospitals might use in seeking reimbursement for these services. Of 150 hospitals in the state, 71 returned the questionnaire and 44 (62%) of those hospitals indicated that they offered at least one nondistributive service, but only two reported that they were receiving reimbursement. The committee found that there are two reimbursement mechanisms available to cover cost of nondistributive services: (1) direct billing of the third parties for the individual service, or (2) inclusion of the cost of the service with patient charges for drugs. After meeting with Blue Cross & Blue Shield, the major third-party payer in its state, the committee determined that BC & BS would reimburse the institution for the costs incurred in patient-care services plus an additional 13% overhead fee. In general, the cost of providing the nondistributive service should be reflected in the cost of the pharmacy operating budget, and reimbursement is made to the hospital rather than to the direct provider of the service. A statewide effort can help establish reimbursement procedures for nondistributive services and prevent duplication of efforts by individual institutions investigating reimbursement.

Training pharmacists for pediatric I.V. medication administration.

As the result of a shortage of nursing personnel, satellite pharmacists at University Hospital have assumed the responsibility of administering intravenous medications on selected pediatric nursing units. This article describes a program developed to train pediatric pharmacists to administer intravenous (I.V.) medications and provide decentralized clinical services. The Department of Pharmacy Services and Nursing Staff Development cooperated in defining the duties and responsibilities of I.V. medication pharmacists and developing the training program. Each pharmacist is required to successfully complete two weeks of classroom instruction and four weeks of clinical training conducted on pediatric nursing units. Comprehensive checklists were designed to document all training efforts. The program of I.V. medication administration by satellite pharmacists has been well received by physicians, nurses, and pharmacists. The Department of Pharmacy Services feels that the I.V. medication administration training program played an instrumental role in insuring the success of its pediatric service.

Pharmacist administration of intravenous medications in a pediatric service.

The establishment and operation of a pediatric intravenous medication administration program is described. A program was developed in which a team of pharmacists rotate between assignments in a pharmacy satellite providing unit dose distribution for 87 pediatric beds and an intravenous medication administration program serving a 15-bed pediatric isolation unit. Staffing patterns, pharmacy responsibilities, and a six-week training program for pharmacists are described. The i.v. medication administration program has been well received by nurses and physicians, and pediatric pharmacy personnel view themselves as functioning, productive members of the health care team. Audits indicate the pharmacy-controlled i.v. medication administration program has favorably affected patient care.

A clinical responsibility: maintaining the confidentiality of patient information.

A program to insure the confidentiality of patient information is described along with suggested policies and procedures. Two categories of patient information are discussed. Departmental policies should reflect the institution's policy and specify which employees may have access to the information in a patient's medical record. These policies should relate to professional staff, faculty members, pharmacy students, and supportive personnel. Employees must be made aware that a patient's medical record is confidential and cannot be disclosed without the patient's authorization. The need for maintaining the confidentiality of information on drug usage is also discussed. Specific guidelines are suggested regarding the availability, storage, release, and disposal of records of drug usage. Pharmacy administrators are encouraged to study institutional policies, to develop departmental guidelines for protecting the confidentiality of patient information, and to familiarize employees with established policies.

Developing an educational safety program for pharmacy employees.

The need for developing educational safety programs for pharmacy employees is discussed. A three-part program is offered as a guide for structuring a departmental safety program. Part I deals with environmental hazards such as wet floors, poor lighting, and cluttered walk areas. Precautions that should be taken to avoid accidental exposure to patients with communicable diseases are also included. Hazards that may result from improper handling of materials or equipment are addressed in Part II. Included are precautions for handling chemicals, needles, ladders, and electrical equipment. Proper methods of lifting heavy objects are also discussed. Part III details plans to protect staff members in the event of a fire. Plans for reporting fires and evacuating the pharmacy and hospital are discussed. The outlined program requires self-study by staff members during initial employee orientation, followed by annual retraining. Employees are tested and graded on safety topics, and training records are filed for future reference. The program outlined is thought to offer a simple yet effective means of acquainting staff members with established institutional and departmental safety procedures.

Physician use and evaluation of a hospital-based drug information center.

The use of a hospital-based information center by physicians was investigated. A questionnaire was used to gather information from physicians using the services of the center. The study was conducted over a six-month period. Of the 126 questionnaires distributed, 115 (91.1%) were completed and returned. The number of physicians studied was 100. The five categories of drug information most frequently requested involved adverse reactions, dosage, therapeutic use, availability and toxicity. Physicians used information most frequently for purposes of direct patient care. Evaluations of the quality, accuracy and quantity of information provided by the center were high. Physicians using information for purposes of direct patient care felt the information was clinically significant. Although certain inadequacies were identified, it was concluded that the center serves as a reliable source of comprehensive and accurate drug information for physicians.