Reaching New Heights through Pharmacy Technician Advancement

1. Reaching New Heights through Pharmacy Technician Advancement Ross Thompson, M.S., R.Ph. Director of Pharmacy Services Melissa Ortega, M.S., Pharm.D. Pharmacy Operations Manager

2. Review ASHP Pharmacy Practice Model Initiative (PPMI) Discuss methods for evaluating your practice setting List PPMI recommendations on technician advancement Highlight methodologies for facilitating practice change Discuss ASHP and MSHP initiatives to facilitate change Objectives

3. PPMI Vision and Goals Vision of PPMI To create passion, commitment, and action among hospital and health-system pharmacy practice leaders to advance the health and well being of patients by optimizing the role of pharmacists in providing direct patient care Goal of PPMI Implement the vision by support a futuristic practice model Describe how resources are deployed to provide care. How pharmacists practice and provide care to patients How technicians are involved to support care Use of automation and technology AJHP 2010;67:542

4. Translating Recommendations Into Practice 106 Recommendations ASHP Publications Policy Tools Research

6. Categories of Self-Assessment Criteria Hospital Demographics Optimal Practice Model Characteristics (organization) Optimal Practice Model Characteristics (employee/scope) Advancing Information Technology Advancing Pharmacy Technician Roles Successful Implementation of New Practice model

7. Benefits of Completing a Self-Assessment Identifies gaps Assists with prioritization Generates an action plan Links to resources supporting the recommendation Tracks performance / conformity Provides comparison with other hospitals

8. Optimal Pharmacy Practice Model Characteristics – Part I Definition: Drug Therapy Management is a multidisciplinary team process for selecting appropriate drug therapies, educating patients, monitoring patients, and continually assessing outcomes of therapy. Pharmacist activities in drug therapy management may include, but are not limited to: initiating, modifying ,and monitoring a patient’s drug therapy; ordering and performing laboratory and related tests; assessing patient response to therapy; counseling and educating a patient about medications; and administering medications. Are pharmacists recognized for taking a lead role in providing drug therapy management services to patients at your hospital/health system? 12% Exists in all areas/situations (100%) 50% Exists in most areas/situations (50-99%) 38% Exists only in some areas/situations (1-49%) 0% Does not exist (0%) 0% Not applicable

9. Optimal Pharmacy Practice Model Characteristics – Part II Is medication reconciliation performed by the pharmacy staff at your hospital/health system? 4% Medication reconciliation is performed by pharmacy staff throughout all areas 8% Medication reconciliation is performed by pharmacy staff in some areas 38% Medication reconciliation is partially performed by pharmacy staff in some or all areas 46% Medication reconciliation not performed by pharmacy staff 4% Not applicable

10. Optimal Pharmacy Practice Model Characteristics – Part II If you employ pharmacy student interns, are their duties different from traditional pharmacy technician duties? 50% Yes 38% No 12% Not applicable

11. Advancing the Application of IT in the Med Use Process Has clinical decision support been integrated with computerized provider order entry at your hospital/health system? 23% Exists in all areas/situations (100%) 31% Exists in most areas/situations (50-99%) 27% Exists only in some areas/situations (1-49%) 15% Does not exist (0%) 4% Not applicable

12. Total of 1,025 organizations have submitted data Overall score of 52% compliance with recommendations Northeast region has 171 organizations scoring at 50% Includes 26 of approximately 100 Massachusetts facilities Massachusetts facilities collectively scored 51% Advancing technicians’ role is the nation’s lowest score at just 28% compliance with recommendations PPMI Results: Massachusetts

13. Initiating the Change Effort at Tufts MC

14. What to Prioritize Total Score: 54% Optimal Pharmacy Practice Model Characteristics Part 1 and 2 70% and 48% (66% and 41% nationally) Advancing the Application of IT in the Medication Use Process 45% (46%) Advancing the Use of Pharmacy Technicians 44% (28%) Successful Implementation of New Pharmacy Practice 52% (60%) Items Completed: 37 Items Close to Completion: 22 Items Needing Completion: 39

15. Integrated Practice Model via 5 Service Delivery Teams Each service team will consist of 2 or 3 pharmacists, 1 resident, and 1 technician on day shift; then either 1 or 2 pharmacists on weekday evening and weekend day shifts Each service team is responsible for providing our complement of services to a specific patient care area Acute Care Pharmacy Practice Model

16. Team based practice model: specialist, generalists, technician, resident, and student Pharmacist time devoted to clinical services Pharmacy core services provided to every patient, every day Targeted services for high risk or complex patients / therapies Drug distribution facilitated by pharmacy technicians How We Will Structure Our Acute Care Services

17. Creating a Vision

18. Members of the Tufts Medical Center Department of Pharmacy Services are sought after for their expertise and are accountable for medication therapy outcomes; providing the best possible care for every patient, every time. Vision Statement

19. Pharmacy Practice Councils Four Councils Chaired by staff Wrote Charter Establish goals Plan and make change

20. Change Management Overview States and Phases Desired State Transition State Current State Remedy/Vision Pain/Urgency Change is a process Themes can be categorized into 3 states

21. The status quo is not an option! “If you don’t like change, you are really going to hate being irrelevant” - Tom Peters

22. Change Models Key Principles Documented in the literature with success in various settings Business Non-profit associations Healthcare organizations Types of change models 8 steps of change management Healthcare redesign and improvement models Pharmacy specific Ray MD, Breland BL. Am J Health-Syst Pharm—2011;68:1138-45

23. Change Models help you think about… The what, why, and how to make it work for technicians and pharmacists in a new world Where to start? What are the best practices in raising the bar for technician roles? Who are the key stakeholders? What are the barriers and challenges? Inter professional relationships on the front lines-what works what doesn’t when roles change? How to get buy-in? Resources to build advanced technician workforce – where to go and how to use? What are the one or two keys to your success? What will you measure to demonstrate value?

24. Kotter’s 8-Step Change Model 1. Create Urgency 2. Form a Powerful Coalition 3. Create a Vision for Change 4. Communicate the Change Vision 5. Remove Obstacles 6. Create Short-Term Wins 7. Build on the Change 8. Anchor the Changes Leading Change, John P. Kotter, HBR, 1998

25. The 8 Step Approach to Leading Change Applied:Mobilizing Practice Change:Advancing the pharmacy practice model through a technician advancement council Leading Change, John P. Kotter, HBR, 1998 Kotter JP. Leading Change: Why Transformation Efforts Fail. Harv Bus Rev. 1995;59-67.

26. Helping others see the need for change and the importance of acting quickly • Convince at least 75% of your people that the status quo is more dangerous than the unknown Step One: Create Urgency • Tufts Medical Center’s Actions: • Distribute appropriate background materials and highlight gaps • Examine the best practices & understand the literature • Establish structure around initiative • Potential Pitfalls: • Underestimating the difficulty of driving people from their comfort zones • Becoming paralyzed by risks

27. ASHP PPMI Tuft’s Action Plan Identify Gaps High Impact: High Feasibility:   

28. Areas of Opportunity for Technicians Examine Best Practices and Literature Am J Health-SystPharm—Vol 68 Oct 1, 2011 UHC Practice Advancement Committee Survey*: Areas of Opportunity for Technician Deployment- Apr 2012

29. Establish Structure Around Initiative Pharmacy Councils

30. Establish Structure Around Initiative Change Management Style- Finding the Balance

31. Technician Advancement Council Establish Structure Around Initiative Council’s Charter Positions Facilitator Chair Liaisons Objectives Deliverables Outcomes Guideline Expectations Minutes and agendas Participation and attendance

32. Identify key stakeholders, educate them and build their interest and support Step Two: Form a Powerful Coalition • Tufts Medical Center’s Actions: • Assemble a group with shared commitment and enough power to lead the change effort • # technician members > # pharmacist members > # administrative members • Identify and meet with stakeholders Potential Pitfalls: • No prior experience in teamwork at the top

33. Examples of Advanced Technician Roles Tufts Medical Center’s Experience

34. Council Membership and representation 12 members Technicians (8) Pharmacist (3) Chair Technician Facilitator Manager Ad Hoc Nurses Stakeholders Pharmacists Nurses Technicians Council Membership

35. “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.” – Margaret Mead

36. Step Three & Four: Create and Communicate a Vision for Change • Create a picture of the future & how it will be different from the past • Use every vehicle possible to constantly communicate the new vision & strategies • Tufts Medical Center’s Actions: • Establish the vision = Council’s Objective • Strategy for realizing the vision • Analyze and plan • Council work Potential Pitfalls: • Presenting a vision that’s too complicated • Under-communicating the vision

37. Putting it all together… “Vision without action is simply dreaming” Establish the Vision • Council’s Objectives • Expand the role of team based technicians • Create opportunity for pharmacy technician specialization • Maintain competent workforce to manage growing complexities of the med use system

38. Strategies for Achieving the Vision Analyze and Plan List expected changes within the next two years Team based technicians Tech-Check-Tech Perform current state analysis Define each technician’s role Date Collection Log Review internal results Current state analysis vs pilot project

39. High Impact/Importance Activities currently being performed

40. Align information, systems and processes to the vision • Identify resistors and help them see what is needed Step Five: Remove Obstacles • Tufts Medical Center’s Actions : • Encourage risk taking and non-traditional ideas, activities, and actions • Recognize current activities that add value • Identify boundaries, constraints, and assumptions • Recognize resource needs and availability • Create a plan to overcome obstacles • Potential Pitfalls: • Failing to remove obstacles

41. Identifying obstacles: Council Feedback Questions to ask What potential physical barriers in a pharmacy department should be considered? What additional education and training will individual members need in order to implement the desired change? What types of resistance or “push-back” might be anticipated from pharmacist , nurses, or others outside the pharmacy department?

42. Plan Overcoming Obstacles Key elements for success Advocate for technological resources to support safe, effective, and efficient medication use system and aid the role of pharmacy technician Collaboration with other councils Streamline operations and reallocate resources to allow for a decentralize technician model Operations Improvement Council Optimize decentralized pharmacy service Pharmacy Advancement Council Prepare, train, and educate technicians to take on new roles Education and Training Council

43. Plan for visible improvements in performance, or “wins” • Create short-term targets, not just one long-term goal Step Six: Create Short-term Wins • Tufts Medical Center’s Actions : • Separate initiatives to deliverables • High impact/high feasibility items • Prioritize “low hanging fruit” • Define and engineer visible performance improvements Potential Pitfalls: • Leaving short-term successes up to chance

44. High impact & High Feasibility Items Activities NOT currently performed High Impact (value-added activities): High Feasibility:   

45. Prioritize “Low Hanging Fruit” • 5. Initializing or receiving communication • Missing doses • Medication status • High utilization • Drug shortages 7. Discharge process- insurance and prior authorizations inquiries 6. Oversight when patient’s are transferred 4. Drip Rounds-Monitoring of continuous infusions 2. Daily monitoring of override reports 3. Collection of and following up of written orders 1. Pulling and receiving narcotics Low hanging fruit = All distributive functions that do not require clinical judgment currently completed by a pharmacist

46. Implement the Process: Create Short Term Wins • Incremental approach versus big bang • Used the Plan, Do, Check, Act (PDCA) model to guide implementation • High impact/high feasibility items • “Low hanging fruit” Override Reports • A P • C D • Plan: report collected and reviewed by technician. • Do: Reallocate task - Follow up on discrepancies with Pharmacist and/or health care provider. • Check: Number of overrides reconciled accurately • Act: Continue with plan Improvement Ramp

47. Consolidate improvements and produce more change • Leverage quick wins to build momentum for change • Communicate change, the impact and the value; provide ongoing documentation Step Seven and Step Eight: Build on the Change and Anchor the Changes • Tufts Medical Center’s Actions: • Build momentum for change • Publish results (tell the story) • Demonstrate value Potentials Pitfalls: • Declaring victory too soon

48. Tuft’s Experience Pharmacy Extenders- Team Based Technicians Pediatric team based technician Responsible for specific nursing units Delivering IV run, oral syringes, pediatric pull, narcotics, refilling automated dispensing systems, finding missing doses, following up with stat doses Available by pager Available for assisting decentralized pharmacist with request Metrics Percentage decrease of pharmacist time on task of distributive functions Increased level communication between inpatient pharmacy and the units Increased communication about medication turn around time

49. Tuft’s Experience Pharmacy Extenders- Team Based Technicians Lessons learned Not everyone can be placed in roles where they need to interact with other health care providers Amount of autonomy Define responsibilities and medication distribution model clearly New tool developed Pediatric performance indicator log Recognized benefits Potential to reduce readmission rates, prevent or mitigate medication errors

50. Tuft’s Experience Measure the Impact Recognize and reward new behavior to embed into new culture