Management Dilemmas: Integrating New and Established Practices

1. Management Dilemmas: Integrating New and Established Practices South Carolina Society of Health System Pharmacists Spring Symposium, 2008 Joel Melroy, PharmD, MS Manager, Ashley River Tower Pharmacy Services Medical University of South Carolina

2. Ashley River Tower

3. Ashley River Tower • 156 bed service line hospital • Heart & Vascular Service Line • Digestive Diseases Service Line • Patient Tower: acute care + ICUs • Diagnostic & Treatment: ORs, Cath labs, IR • Chest Pain Center • Clinics Projected 60% capacity – budgeted staffing

4. Ashley River Tower • Inpatient Pharmacy • Clinical and distributive services • Inpatient units, procedure areas, clinics • Automated Dispensing Machine (ADM) Service • Operating Room (OR) Pharmacy – Carole Russell • Pre-op, OR, PACU • Retail Pharmacy – Heather Kokko • Outpatient & employee prescriptions

5. Overview • Planning • Resources • Operations • Clinical Practice • One week prior to opening • One week after opening • One month after opening

6. Key Observations A large project such as opening a new hospital requires teamwork This feat could not have been accomplished without teamwork from the pharmacy director, management team, and staff

7. Planning • Dilemmas: • New standards, unplanned facility surprises • BoP, DHEC, and DEA licensing • <797> and revision – 12/07 • Facilities • Distribution Plan • Point of Care medication administration • Hybrid cartfill-cabinet model • Courier service • ADM cabinets, configurations, inventory • Technology Implementation • BCMA, Smart Pumps, CPOE • Inventory • Accounts, contracts • Robot/cartfill in a separate facility • Dependent on another department to provide courier service • BCMA, Smart Pump rollout • Too much vs. not enough

8. Facility Surprises…

9. Resources • Personnel • Attract and select the best people • Train sufficiently • Share resources, if necessary Dilemma: Midnight Pharmacists • Equipment • Purchase redundant equipment? • Support for new automation/technology Dilemma: Medication Transfer Carts

10. Operations

11. Operations • Daily order: delivered to ART • ADM service • ART staff • Administrative/Superuser support provided by MUH • Courier service • Distribution Center, Compounding, AIP, ART • Up to 8 runs per day Dilemmas:Incorporating workflow of two separate operations, ADM training, courier

12. Clinical Practice • Established model: specialist • Clinical pharmacists perform order entry functions and specialists round with teams • Desired model: integrated w. “coordinator” • Clinical pharmacists expand their roles and specialists coordinate activities, initiatives Dilemma: changing practice models with practitioners with established roles

13. One Week Prior… • Limited access to hospital • Hospital DHEC licensing • Successful BoP inspection, DEA • Licensed on 1/30 (Wednesday) • 1st drug order: 1/31 • Stocked 3 pharmacies + 50 ADMs • “Completion”: 2/3 • Opened: 2/4 We didn’t have time for dilemmas!

14. One Week Prior… • Issues • Completing the initial drug order • Used purchasing data from MUH • Did not order non-formulary medications • Planned to utilize MUH inpatient pharmacy for medications not ordered initially (tube system) • Medication security/transport • ~50 to 90 patients expected to move to ART • Medication transport bags and labels • Filling ADMs + inability to access hospital • Midnight pharmacists not fully trained • Smart Pump rollout – all IV medications to be changed out at arrival to ART

15. Opening • Incident Command Team – “Disaster” • Medication Staging – MUH • Supply Team Leader – ART • Daily meetings from Thursday until Sunday • Moved 59 total patients with 7 admissions in 5.5 hours • Pharmacists located on floors and in central pharmacy • Pharmacy team – extremely responsive to changing needs & stress on the floors

16. One Week After… • Inventory stabilizing • Decentralized pharmacists on floors • Daily staff meetings • Issues: • Courier service not consistent • Medications needed for clinics • IT issues (fax server, computers) • Central pharmacy organizational patterns • Distribution/paperwork • Staffing • Technician/pharmacist training

17. One Month After… • Weekly staff meetings • Ongoing training • Courier/distribution becoming smoother • Continuing issues • Staffing/training • Gaining resources for increasing staff levels • Some IT issues (fax machines) • Changing to an integrated practice model • Workload increasing – census above the projected 60% level

18. Lessons Learned • It takes many dedicated people working as a team to accomplish such a large feat • Some change can occur in a minute and other change takes more time • Listen to your staff and meet frequently – communicate • Listen and respond to nurse/physician needs while remaining calm • Be action-oriented and responsive • Set up as many systems as possible prior to opening (e.g., distribution, courier, clinic meds) • Complex problems require complex solutions…don’t settle for the “quick fix” • Be visible to your staff, nursing staff, and physician staff • Be involved with multidisciplinary operations committees and other teams before and after the move – you will gain insight on system issues and staffing patterns • Be flexible and open-minded • Be surrounded by high performers

19. Kristen Baker Nicki Balchin Courtney Bath Sharon Fahey Carrie Flippen Charles Garred Tom Gnau Phil Grech Chanda Harrison Mary Jo Jack Shantee Jacques Charlotte Johnson Bruce Keck Staff • Devin Matthews • Crystal McKinley • Kathryn Noyes • Johnte’ Porter • Emily Poston • Becky Schneider • Trish Schuler • Dianna Sellers • Kendra Seward • Sam Solomon • Walt Uber • James Walker • Joyce Warren • Marina Williams • Kristen Baker • Nicki Balchin • Courtney Bath • Sharon Fahey • Carrie Flippen • Charles Garred • Tom Gnau • Phil Grech • Chanda Harrison • Mary Jo Jack • Shantee Jacques • Charlotte Johnson • Bruce Keck

20. Management Team • Paul Bush • Carole Russell • Chris Fortier • Heather Kokko • Joe Mazur • Matt Maughan • Kelli Garrison

21. Questions?