Annual Pharmacy Conference SOARS Findings

1. Annual Pharmacy ConferenceSOARS Findings Ravella Gooden-Dickinson SOARS Program Coordinator March 27, 2008

2. SOARS Mission Assist VHA Medical Facilities in being ready for any internal or external review. Goal is to provide optimal services every day!

3. SCOPE OF REVIEW

4. What We’ll Cover Today • SOARS Status Update • SOARS Findings • OIG Findings and reviews • “The Common Threads” • Where do we go from here • Questions and answers

5. STATUS UPDATE • Started in 2003 • To date, completed 178 total visits. 138 initial visits at all VHA medical facilities and Health Care System and completed 40 triennial visits. • 250 Internal Consultants and 30 Leaders • Developed 42 assessment guides in collaboration with Program Offices • Changed in July, 2006 to compulsory visits with comprehensive written reports

6. Continued STATUS UPDATE • Conduct 6 Audio Training Conferences per year • Produced 2 Training Film – “Pharmacy Assessment” and “SPD Assessment” • Added new clinical focus: “tracers”

7. OIG Pharmacy Reviews • Review of VA Medical Facility Compliance with Controls over Prescription Drugs (05-00877-17) • Audit of VA's Consolidated Mail Outpatient Pharmacies (CMOP - 06) • Pharmacy Operations. (07) • Management of Selected Prescription and OTC Medications (08)

8. FY 07 OIG CAP Findings(30 facilities) • Strengthen QM processes to accurately reconcile medications during admission, transfer, & discharge • Improve compliance w/ monitoring for medication expiration dates • Improve QM processes in PT safety, medication management, & clinic access

9. FY 07 OIG CAP Findings(30 facilities) • Ensure unattended medication carts are locked • Improve compliance w/ medication refrigerator temperature monitoring • Achieve full compliance with Medication Reconciliation requirements

10. MEDICATION MANAGEMENT(SOARS Trended Findings) • Significant Concerns: • Unsecured medications • Medication Reconciliation Processes • Continuing Concerns: • Storage and labeling of medications • Inconsistent and continuous medication refrigeration monitoring • USP 797 compliance • The Weak Link: • The UnAnnounced Inspection Program

11. More SOARS Findings • Multi-use vial dating and outdated medications in general • Patient Safety Goal #6- Sound alike Look alike drug identification (usually seen in Pharmacy, not always on ward) • Vault and/or Pharmacy Security - Ensure that either the police or pharmacy print lists for analysis of people entering the vault and off hours pharmacy(24/7) on a random basis frequently. • Update local policies to reflect current national requirements for in/outpatient pharmacy

12. …Continued SOARS Findings • Unannounced Inspection Program: • Not analyzing data or trending findings • Predictable inspections • Clear documentation of resolution of discrepancies • Proper medication dispensing /documentation/provider ordering (many facilities beginning to utilize nurses in non-clinical roles to conduct record reviews) OIG reports…”drug thefts…diverted controlled substance and record altering…stealing pain medication…”

13. Not Fixed but Improved • Drugs held for Destruction • Follow-up on deficiencies noted in Annual Police or other reviews • Proper ordering and receiving of controlled substances by Pharmacy • Methadone Clinic Oversight • Drills for the movement of emergency Pharmacy Caches

16. SOARS Program Goals • Standardization of visits (2 – FT Leaders) • Increase involvement of VISNs and Program Offices • Improve skills of consultants and leaders (training videos) • Stay Ahead…..be proactive vs. reactive • Promote “Continuous Readiness”!

17. Ron Boneberg Sharon Castle Roy Coakley Maria Favale Mario Franchi David Gray Barbara Ko Randy Koontz John Lowe Ron Lovly Pat Minard Sampath Narayana Eric Richards Bernadette Brown Michelle Shank Mark Slagle Fred Soetje Mick Weiss Questions?THANKS to our SOARS Consultants!