The association between number of learners and pharmacist and technician levels of burnout.

PURPOSE: Little is known about the relationship between learner load and pharmacist and pharmacy technician burnout. Therefore, the purpose of this study was to examine the association between burnout and the number of learners (residents, students, and new employees) assigned to pharmacists or pharmacy technicians. METHODS: A validated survey to measure burnout and professional fulfillment was administered to employees of a university health system's pharmacy service in 2019. A threshold analysis determined the optimal cutoff for number of learners trained that maximized the ability to predict binary outcomes. Chi-square and Fisher's exact tests were used, and effect sizes between percentages were reported. Finally, the adjusted associations between number of learners and outcomes were assessed using logistic regression. RESULTS: A total of 448 pharmacy staff members were included in the analysis. Of those, 57% (n = 254) worked in ambulatory care, 27.4% (n = 122) worked in an inpatient setting, and 15.7% (n = 70) worked in infrastructure. Pharmacists working in an inpatient setting who reported training 4 or more learners per year indicated significantly higher rates of burnout than those training fewer learners on both a single-item burnout assessment (64.3% vs 31.0%; P = 0.01; effect size, 0.68) and a 10-item burnout assessment (54.8% vs 13.8%; P = 0.01; effect size, 0.91). Similar results were not observed in pharmacists working in ambulatory care and infrastructure positions or in pharmacy technicians. CONCLUSION: Added precepting and training responsibilities may be associated with higher levels of burnout among pharmacy team members, particularly inpatient pharmacists.

Interventions to reduce waste and improve billing compliance with medications in single-dose vials.

PURPOSE: The purpose of this process improvement project was to implement features in the electronic health record to help reduce inappropriate drug waste and Medicare billing noncompliance for injectable drugs in single-dose vials in outpatient settings. METHODS: The pharmacy department mapped processes from order entry to dose administration and claims processing. They used the process map to identify gaps that could lead to inappropriate drug waste. The organization then chose 3 drugs they believed to be at high risk of excess waste and possible billing noncompliance after cross-referencing drug cost, volume of use, and previous Medicare audits in outpatient settings. They tested a grouper and dose rounding on these drugs and compared 3 months of claims before and after implementation to assess the impact on waste and billing compliance. RESULTS: This study evaluated 826 claims before implementation and 1,075 claims after implementation. A total of 455 of 826 (55.1%) preimplementation claims included drug waste compared to 224 of 1,075 (20.8%) postimplementation claims. Twenty-three claims before implementation included an amount of waste exceeding the smallest vial size, putting the institution at risk of billing noncompliance. No claims had excess waste in the postimplementation period. The approximate cost of total drug waste before implementation was $1,397,437, with approximately $23,730 from inappropriate carfilzomib claims. The approximate cost of waste after implementation was $569,041. This equated to a reduction in drug waste of approximately $828,396 for bevacizumab-bvzr, carfilzomib, and ipilimumab. CONCLUSION: Using a grouper and implementing dose rounding, the institution reduced drug waste, saved money, and reduced the incidence of claims noncompliant with Medicare Part B billing requirements.

Implementation of radio-frequency identification technology to optimize medication inventory management in the intraoperative setting.

PURPOSE: Manual restocking and tracking of noncontrolled medications in anesthesia workstations (AWSs) is complicated and time intensive, provides several opportunities for error, and lacks perpetual inventory transparency regarding expiration and lot number. This pre-post study assessed the impact of radio-frequency identification (RFID) technology on restocking of noncontrolled medications in AWSs in relation to workflow, improved patient safety due to reduced restocking errors, and restocking accuracy and efficiency, as well as the estimated costs of on-site medication RFID tagging versus purchase of pretagged products. SUMMARY: Pre- and postimplementation process steps were mapped. Randomized AWS tray audits were conducted to assess patient safety, and AWS tray restocking efficiency was measured through stopwatch studies. Time and costs associated with purchase of manufacturer RFID tagged medications versus manually tagging medications on-site were estimated. Pre-post comparisons were completed using descriptive statistics. Prior to implementation, manual AWS restocking took a mean (SD) of 37.9 (24.7) seconds (range, 4.6-135.9 seconds), compared to 145.9 (50.6) seconds (range, 43.4-314.3 seconds) after implementation. The automated workflow took technicians an average of 108 seconds (1.8 minutes) longer than the baseline time. However, restocking errors were reduced by 64.7% and outdated and missing medications eliminated. Manually applying tags to packages containing 25 vials took a mean (SD) of 174.8 (19.8) seconds (range, 131-218 seconds) for smaller vials, compared to 128.1 (21.6) seconds (range, 102-166 seconds) for larger vials. Manual tag application was also more expensive than purchasing of pretagged vials. CONCLUSION: Automated RFID technology for AWS restocking decreased restocking errors but increased the length of time to complete the restocking process.

Angiotensin-converting enzyme inhibitors reduce community-acquired pneumonia hospitalization and mortality.

BACKGROUND: Pneumonia is a global disorder and a common reason for prolonged hospitalization. Angiotensin-converting enzyme inhibitors (ACEi) have pleiotropic effects that support a role in modulating pneumonia, but results have been controversial. OBJECTIVES: The present study was conducted to elucidate an ACEi-induced pneumonia benefit in at-risk neurologically impaired population and to determine whether a mortality benefit exists. METHODS: A cohort study using a large health-system of 29,011 unique ACEi users and 1635 case patients 65 years of age or older without neurological disorders affecting swallowing who were admitted with community-acquired pneumonia hospitalization and followed up from January 1, 2015 to December 31, 2019 (5 years). The association between ACEi use and pneumonia hospitalization and mortality were determined after propensity score matching using Cox and logistic regression. RESULTS: The experimental cohort was 74.9 ± 7.3 years and 51% were male. ACEi users had lower odds of acquiring pneumonia versus ACEi non-users (odds ratio) 0.72 [95% Confidence Interval (CI) 0.51 to 0.99]; p = 0.048. The risk of short-term mortality (<30 days) (HR) 0.42, p < 0.001 and long-term mortality (≥30 day) (HR) 0.83, p < 0.002 was significantly lower for ACEi users compared with the ACEi non-users. CONCLUSIONS: ACEi use in patients at risk of pneumonia without neurological swallowing disorders is associated with reduction in hospitalization and lowering of short- and long-term mortality. Given the high incidence of morbidity and mortality associated with pneumonia, and the susceptibility in older populations with underlying cardiovascular or renal disease or social dependencies, our data support the prescribing of ACEi in these populations to reduce pneumonia hospitalization risk as well as short- and long-term mortality.

Implementation of implicit bias awareness and action training in a pharmacy residency program.

PURPOSE: To implement an implicit bias awareness and action seminar program for the University of Utah Health pharmacy residency program and measure knowledge, awareness, and comfort around race-related topics. SUMMARY: An implicit bias awareness training program was implemented with a pre- and post-training survey to measure knowledge, comfort, and confidence around understanding and addressing biases. Fifty-one residents and preceptors participated in the implicit bias training, and 47 (92.2%) consented to take the survey. Twenty pharmacy residents and 27 preceptors attended at least 1 of the 4 training modules and completed the pre- and/or post-training survey. Eighteen of 20 residents (90.0%) and 19 of 27 (70.4%) preceptors completed the pretraining survey (37 total), while 11 of 20 residents (55.0%) and 10 of 27 (37.0%) preceptors completed the post-training survey (21 total). On the post-training survey, more correct answers were obtained for knowledge-based questions and a higher number of responses of strongly agree or agree was observed when assessing participants' comfort and confidence in addressing personal biases, bringing marginalized people into a conversation, addressing biased situations, and intervening when bias is observed. CONCLUSION: After training, higher scores were attained on the survey for overall comfort and confidence in addressing personal biases and identifying and acting on witnessed biases.

Burnout, professional fulfillment, sleep impairment, and self-compassion within an academic medical center pharmacy department.

PURPOSE: To examine the prevalence of burnout, professional fulfillment, sleep impairment, and self-compassion within an academic medical center pharmacy department across varying job titles and practice settings. METHODS: In fall 2019, pharmacy staff completed a REDCap-based survey that consisted of a validated instrument relating to burnout, professional fulfilment, sleep-related impairment, and self-compassion. Burnout was measured by both single-item and extended 10-item questions on the survey. Survey outcomes from each domain were compared between pharmacists and pharmacy technicians/interns, as well as among practice settings (inpatient, ambulatory care, and infrastructure). RESULTS: A total of 593 surveys were completed by pharmacy personnel, representing a preliminary response rate of 71.8% (593/826). A total of 505 survey responses were analyzed (235 [46.5%] for pharmacists and 270 [53.5%] for pharmacy technicians/interns). Inpatient pharmacists reported the highest level of burnout (50.7%), followed by ambulatory care pharmacists (29.3%) and those working in infrastructure (24.3%). Pharmacy technicians working in infrastructure reported the highest level of burnout (36.4%), followed by inpatient (30.8%) and ambulatory care (28.3%) pharmacy technicians. There was no association between job type or location and burnout according to both single-item and 10-item burnout measures. A higher rate of burnout, sleep impairment, and decreased self-compassion and a lower rate of professional fulfillment were observed for inpatient pharmacists compared to pharmacists in ambulatory care or infrastructure. Except for higher rates of reported professional fulfillment, a similar trend was observed for pharmacy technicians. CONCLUSION: Burnout was reported across the pharmacy team regardless of practice site.

Evaluating hematology/oncology clinical pharmacist activities via self-reported work sampling.

PURPOSE: Hematology/oncology clinical pharmacists' work activities have been described in previous literature, but time spent on pharmacist tasks has not been well characterized. Random work sampling (WS) is a form of activity assessment to determine the proportion of time spent in various types of work. Based on results from previous WS evaluations at University of Utah and its Huntsman Cancer Hospital, activities were changed to maximize time dedicated to clinical activities and pharmacists' benefit to providers and patients in both inpatient and ambulatory care settings. Therefore, updated random WS evaluations were completed during spring 2019 and fall 2020. METHODS: Personal digital assistant (PDA) devices were used to record hematology/oncology clinical pharmacists' onsite or remote location and work activity data. Data were collected 8 times per hour on weekdays, with a goal of 275 observations per pharmacist. Results were then classified as clinical, professional, or technical activities. RESULTS: In 2019, 9,079 observations were recorded by 31 onsite pharmacists. In 2020, 28 pharmacists recorded 8,803 observations (5,524 during onsite work and 3,279 during remote work). The overall distribution of pharmacists' work activities remained stable between 2019 and 2020, with 89% of activities classified as clinical or professional. Pharmacists spent a smaller proportion of time on in-person communication in 2020, balanced by increases in chart review and text-based communication. Onsite pharmacists reported a larger proportion of clinical activities, while remote pharmacists reported a larger proportion of professional activities. CONCLUSION: Continued WS assessment of work activity patterns will allow identification of opportunities to streamline workflows, maximize pharmacist engagement in clinical activities, and development of remote work policy.

A 2019 evaluation of opioid use disorder treatment resources in rural Utah counties.

OBJECTIVES: The opioid crisis significantly affects residents of rural communities who already experience poor health outcomes based on social determinants. Therefore, this project evaluated the reported availability and accessibility of opioid use disorder (OUD) treatment resources in rural Utah county pharmacies through a multistep process intended to estimate the distance (miles) to registered (waivered) OUD care providers and community pharmacies and, thus, the ability to fill prescriptions for OUD treatment medications. METHODS: First, the United States Department of Agriculture Economic Research Service dichotomous classification scheme was used to identify nonmetropolitan counties. Second, online resources were used to identify the volume of waivered treatment providers and community pharmacies by county. Third, the driving distances to both resources were estimated according to ZIP Code and county. Finally, the immediate availability of filling a prescription for OUD treatment medications was determined by surveying community pharmacists in rural Utah counties. RESULTS: Nineteen of the 29 Utah counties were identified as rural and included in the study. Pharmacists in 50 of the 75 viable pharmacies completed surveys (66.7% usable response rate). OUD treatment medications were immediately available for dispensing in 90% (45 of 50) of the responding pharmacies. Two of the 19 counties (10.5%) lacked a pharmacy, and 6 of the 19 counties (31.6%) lacked a registered OUD treatment provider. Driving distances ranged from 1 mile to 71 miles to the nearest pharmacy and from 1 mile to 96 miles to the nearest waivered treatment provider. CONCLUSION: OUD treatment medications were readily available in some but not all rural Utah pharmacies. However, geographic barriers may prevent reasonable access to treatment providers and pharmacies for residents of smaller, remote communities.

Reduction of phone interruptions post implementation of a central call center in community pharmacies of an academic health system.

PURPOSE: A pharmacy services call center (PSCC) was implemented to centralize pharmacy phone calls and reduce interruptions of dispensing activities in 7 community pharmacies of an academic health center. An evaluation was conducted to define, quantify, and compare the numbers and types of phone interruptions before and 3 months after PSCC implementation. METHODS: Through structured, direct observation of pharmacy staff, the numbers and types of "breaks in task" (BIT) due to phone interruptions and other distractions were identified. A standardized data collection tool formatted on tablet computers was used by trained observers to document BIT for 3-hour time blocks on 5 consecutive business days (2 days of pharmacist observation and 3 days of technician observation, for a total of 10 observation days per pharmacy). RESULTS: Over 5,000 prescriptions were processed during 414 hours of observation (13.3 prescriptions per observation hour). Overall, BIT due to phone interruptions totaled 2.2 BIT per observation hour, with those interruptions reduced by 46.4% overall after PSCC implementation (by 30.0% in 4 small pharmacies and by 57.5% in 3 large pharmacies). Technicians were more likely than pharmacists to be interrupted by phone vs nonphone BIT (eg, distraction by another technician, pharmacist, or patient). Comparison of phone vs nonphone BIT suggested an overall 46.0% reduction in phone BIT in all pharmacies (reductions of 42.4% and 45.0% in large and small pharmacies, respectively). CONCLUSION: PSCC implementation noticeably decreased the amount of phone interruptions and distractions for employees.

Factors influencing rates of human papillomavirus vaccination.

PURPOSE: Failure modes and effects analysis (FMEA) was used to identify ways in which community clinic practices related to suboptimal human papillomavirus (HPV) vaccination rates could be improved. METHOD: FMEA is a standardized safety method that helps determine where processes fail, the impact of failures, and needed process changes. In a quality improvement initiative conducted at an academic health center-based community clinic, a multidisciplinary team used FMEA to map HPV vaccination processes and identify areas for improvement of vaccination practices. Risk priority numbers (RPNs) were assigned to identified failure modes based on likelihood of occurrence, likelihood of detection, and ability to correct locally. Failure modes with the highest RPNs were targeted for process improvements. RESULTS: High RPN failure modes were related to clinic processes for follow-up, immunization status checks during well-child visits, and vaccination discussions during sick-child visits. New procedures included scheduling follow-up vaccinations and reminders during the initial vaccination appointment. HPV immunization rates improved following implementation of these procedures, indicating that clinic processes focused on patient follow-up can impact vaccination series completion. CONCLUSION: FMEA processes can help health systems identify workflow barriers and locally relevant opportunities for improvement. Team-based approaches to care process improvements can also benefit from standardized problem identification and solving.

Assessment of perceived workload in academic health center community pharmacies before and after implementation of a central call center.

PURPOSE: Results of a study to determine whether reducing pharmacy phone call workload through implementation of a pharmacy services call center (PSCC) led to decreased employee workload, improved efficiency, and increased pharmacist availability for patient care are reported. METHODS: A pre-post study was conducted using the NASA Task Load Index (NASA-TLX) instrument. Pharmacists, pharmacy technicians at 7 academic health center community pharmacies, and PSCC staff provided NASA-TLX data over 5 days during 3 data collection periods before and after PSCC implementation. Perceived workload was measured as an overall workload score (OWS) and mean scores for 6 NASA-TLX workload dimensions (mental demand, physical demand, temporal demand, performance, effort, and frustration). RESULTS: Relative to pre-PSCC values, mean postimplementation OWS scores significantly decreased in all 7 pharmacies (from 33.3 to 29.1 overall, p < 0.001) but especially in small pharmacies (from 31.7 to 27.6, p < 0.001). Scores for the physical demand and frustration dimensions were low in both the PSCC and in the 7 pharmacies, while scores for the performance dimension remained high (range, 6.8-8.3). In general, scores for all other measured NASA-TLX dimensions decreased after PSCC implementation, more so at smaller pharmacies. The PSCC staff mean OWS score increased over time (from 26.8 to 28.6, p < 0.0001) but remained near the overall pharmacy average of 29.1. CONCLUSION: Use of the NASA TLX allowed for a direct subjective measurement of workload as perceived by pharmacy and PSCC employees before and after PSCC implementation. Long-term effects of the PSCC on workload should be assessed.

Implementation of a centralized mail-order pharmacy service.

PURPOSE: The development and implementation of centralized mail-order pharmacy services in an academic healthcare system are described. SUMMARY: The use of mail-order pharmacy services continues to increase, as mail-order services offer patient benefits such as reduced copayments and improved clinical outcomes. Prior to undertaking an initiative to improve its mail-order pharmacy services, the University of Utah Health system's pharmacy department offered decentralized mail-order pharmacy services at all of its retail pharmacies, but there was no standardized process for processing mail-order prescriptions or providing phone support to mail-order patients. Centralized mail-order pharmacy services were developed and implemented by creating (1) a standard process for mail-order pharmacy services, (2) a centralized mail-order prescription filling center, and (3) a call center to support mail-order pharmacy services. Implementation of centralized mail-order pharmacy services resulted in an almost 50% reduction in time spent by pharmacy team members on mail-order prescription filling and packaging tasks. Use of a central call center resulted in a decreased call abandonment rate and contributed to a decreased pharmacy workload resulting from an overall reduction in call volume due to an increased rate of first-call issue resolution. CONCLUSION: Establishment of a centralized mail-order pharmacy service along with operational and infrastructure improvements resulted in improved quality and regulatory compliance and enhanced labor efficiency and patient communication.

Effect of a central call center on employee perceptions of safety culture within community pharmacies in an academic health system.

PURPOSE: This study evaluated employee perceptions of safety culture in 9 health-system-owned community pharmacies using a safety culture survey before and after implementation of a Pharmacy Services Call Center (PSCC) designed to reduce distractions through reduction of phone volume related to refills and prescription readiness. METHODS: The Agency for Healthcare Research and Quality (AHRQ) Community Pharmacy Survey on Patient Safety Culture (CPSPSC) was used to collect employee safety culture perceptions pre-post PSCC implementation. A percent positive score (PPS) was calculated for each of 11 CPSPSC composite questions and for 1 overall rating of patient safety question based on AHRQ-suggested analytic procedures. Pre-post PSCC implementation, PPSs were compared using a chi-square test. RESULTS: Overall, the lowest composite PPS (Staffing, Work Pressure, and Pace) and the highest composite PPS (Patient Counseling) ranked the same in both survey periods. Of the nine PSCC pharmacies, statistically significant (p < 0.05) PPS improvements occurred in 4 composites including Teamwork (11.9%), Communication About Mistakes (18%), Staff Training and Skills (20.6%), and Staffing, Work Pressure, and Pace (11.8%). PSCC pharmacies also reported a 9.3% (NS) improvement in overall rating of pharmacy patient safety post PSCC implementation. Separate analysis of pharmacist responses was consistent with pharmacy level results, but technician results differed slightly in overall rating of safety perceptions. CONCLUSION: Presence of the PSCC appeared to increase pharmacy employees' perceptions of safety culture in the community pharmacies, an integral part of overall patient safety.

Use of multiple methods to measure impact of a centralized call center on academic health system community pharmacies.

PURPOSE: The process and methods used in an impact assessment of a centralized pharmacy call center on community pharmacy employee patient safety climate perceptions, telephone distractions/interruptions, and prescription filling efficiency are described. SUMMARY: A broad-based team designed a multi-faceted, pre-post call center implementation analysis that included multiple change assessment measures. First, yearly administration of the Agency for Healthcare Research and Quality Community Pharmacy Survey on Patient Safety Culture was used to assess patient safety climate based on employee perceptions of a safe working environment and potential for errors due to interruptions and distractions. Evaluative measures of staff workload that assessed telephone interference with prescription filling activities pre and 3 months post implementation included (1) the NASA Task Load Index, (2) multi-tasking observations through shadowing of pharmacists and technicians to count number of interruptions/distractions per prescription "touched," and (3) self-reported work sampling to assess proportional time estimates of clinical, professional, and technical activities. Finally, pharmacy efficiency and prescription filling capacity were assessed using operational measures (prescriptions filled, patients served, phone call volume changes, prescription rework counting). Data analysis included summary statistics, Student's t-test, and chi-square analysis, as appropriate, in addition to assessing convergence and agreement among measures. Every evaluative method showed a positive outcome from call center implementation, although individual pharmacies may have accrued greater benefit from call reduction than others. CONCLUSION: Multiple analysis methods can be used to evaluate the impact of workflow changes.

Cost-Sharing Requirements for the Herpes Zoster Vaccine in Adults Aged 60.

Background: Rates of zoster vaccination in US adults aged 60+ were approximately 30.6% in 2015. Out-of-pocket cost-sharing has been identified as a major barrier to vaccination for patients. To date, herpes zoster vaccine cost-sharing requirements for adults aged 60 to 64 has not been described. Objective: Compare the cost-sharing requirements for zoster vaccination in adults aged 60 to 64 and adults aged 65+. Methods: A retrospective cohort design examined pharmacy claims for zoster vaccination from the Utah All Payer Claims Database for adults aged 60+. Descriptive statistics and a 2-part cost model compared cost-sharing requirements for adults aged 60 to 64 and adults 65+. Results: Of the 30 293 zoster vaccine claims, 13 398 (45.8%) had no cost-sharing, 1716 (5.9%) had low cost-sharing (defined as $1 to less than $30), and 14 133 (48.3%) had high cost-sharing (defined as $30 or more). In the cost models, adults aged 65+ had higher odds of any cost-sharing (odds ratio = 39.86) and 29% higher cost-sharing as compared with adults aged 60 to 64. Conclusions: Adults aged 60 to 64 encounter lower cost-sharing requirements than adults aged 65+. Providers should be cognizant of this dynamic and encourage zoster vaccination prior to the age of 65.

The effect of a prescription order requirement for pharmacist-administered vaccination on herpes zoster vaccination rates.

OBJECTIVE: To determine the effect of a prescription order requirement for pharmacist-administered zoster vaccination on zoster vaccination in adults aged 60+. METHODS: A 50-state law review of statutes and regulations regarding pharmacists' ability to administer the zoster vaccine with/without a prescription order was performed. States were classified as prescription order required or not required as of January 1, 2014. Data on adults aged 60+ were obtained from the 2014 Behavioral Risk Factor Surveillance System (BRFSS). Chi-square tests and multilevel logistic regression models with and without propensity scores methods were used. RESULTS: Of the 50 states, 39 and the District of Columbia did not require a prescription order. After propensity score matching, zoster vaccination rates for adults ages 60 and older were significantly higher in states that did not require a prescription order (23.0% vs 21.1%, p = 0.0022). The propensity score-matched multilevel logistic regression model for adults aged 60+ found modestly higher odds of HZ vaccination for states that removed the prescription order requirement (OR 1.17, 95% CI 1.01-1.35). Similar estimates were found across other methodologies employed and age strata, although statistical significance varied. CONCLUSIONS: Prescription order requirements are associated with HZ vaccination rates. By removing a prescription order requirement, states may be able to promote increases in HZ vaccination in adults aged 60+.

Harmonization of technology across an integrated delivery network.

PURPOSE: A standardized blueprint for use when harmonizing or standardizing pharmacy automation and technology resources across individual institutions or an integrated delivery network (IDN) of institutions is described. SUMMARY: Whether to strive for standardization (use of the same vendors and equipment) versus harmonization (use of various technologies to meet patient-specific needs and organizational stability requirements) and how to coordinate activities across IDNs consisting of 3-30 or more hospitals are common questions due to consolidations in the healthcare industry. For most IDNs with legacy systems, harmonization may be the better option. Large-scale harmonization initiatives require significant planning and coordination involving all affected parties. Detailed project plans should include the compiling of all associated harmonization costs that involve human resources, information on ongoing services and equipment, and program schedules for multiple concurrent projects in order to provide a framework for planning and coordination. Part of the planning process for harmonization efforts should include an extensive current-state analysis that includes review of contracts and vendors. Final harmonization decisions should be based on a mix of vendor recommendations, best practices, and accommodation of current practices that result in the lowest complexity of system redesign with regard to existing systems. When harmonizing existing technologies, planning must also consider the impact of the change to both the organization and individual users. CONCLUSION: Harmonization is an evaluative process whereby process variation due to automation and technology variability can be reduced and organizational interoperability to meet patient-specific needs can be promoted.