Implementing a Decentralized Model

1. Implementing a Decentralized Model

2. It all began with the burning platform…. • Several factors contributed to the need to change our practice model: • Employee Survey indicated a very large gap between staff and clinical pharmacists, general dissatisfaction with development opportunities • Current model had been in place for decades • While the old model had worked in the past for moving clinical initiatives forward, there are now too many new rules/regs to not distribute accountability

3. My Responsibility is to…. • Create a model where our patients receive the best care possible • Create a challenging and rewarding work environment for all employees • This meant: • Redesigning! • Reassigning!

4. Prior to the new model: • Clinical pharmacists worked Monday-Friday, no weekends, no holidays. • Clinical pharmacists were not trained to do order entry. • Clinical pharmacists were only ones to do coumadin dosing, antibiotic monitoring, committee activities. • Staff Pharmacists were assigned either to “dispensing” in main dept and one pharmacist/day did all “clinical” work (pharmacokinetics). • Day shift pharmacists worked almost all “days.” Evenings worked almost all “evenings,” etc.

5. Held a Mandatory Pharmacist Meeting • Acknowledged that a significant problem existed that not only contributed to low morale, but patient care could be improved • Laid out the general vision & framework for a new model • Gave complete staff ownership to design the new model!

6. VISION: The New Model • Move from a primarily centralized model to a decentralized model for both order entry and clinical activities • Divide hospital into “pods” based on geography and service lines • ALL pharmacy staff will have a variety of responsibilities for the success of the department = BETTER PATIENT CARE

7. VISION: The benefits • Improve relationships within our department and integrate responsibilities • Improve Nursing-Pharmacy Relationship • Improve turn-around-time • Less congestion in main pharmacy • Improve compliance with core measures, dangerous abbreviations, meds rec…etc • Focus on key service lines that need additional expertise (oncology, peds, etc) • Improved pharmacist job satisfaction with clinical activities and pod ownership to improve patient care in their assigned area

8. Task Force • 2 Teams: • Team 1 (Implementation Team):Designed layout, (looked at workload from statistics/services), divided hospital into PODs, determine necessary hardware (laptops, cell phones, desk space, etc). • Team 2 (Schedule Team): Assigned primary/secondary lead people in each area! Put together a schedule with only our existing resources to make it happen!! On paper, there was no reason why we couldn’t move to this model. In practice, it was difficult for everyone to imagine how we could staff this model

9. Major Distinctions: • We did not add any FTEs • Pharmacy Leadership provided only guidance, did not dictate design • Pharmacy Leadership did not assign lead personnel, no “favorites” • Clinical Staff had to learn how to do order entry • Staff pharmacists could not “hide” in the dispensing role

10. Each POD is responsible for: • Order Entry (using commercial order imaging system) • Pharmacokinetics • Medication Reconciliation • Renal monitoring • IV to PO • Watching for dangerous abbreviations • Core Measures • Identifying therapeutic duplications • Discharge Counseling* • Rounding with Physicians* • Coumadin Dosing* *Not available in all areas

11. Implementation Phase I: • Order Imaging System implementation • Identified physical space in each area/phones/computers • Nurses were so excited about new model, they “found” space • Clinical Pharmacists trained on Order Entry • Piloting began by having every person rotate through different areas to find out what areas they liked best • Created POD specific reports to guides interventions • Distributed survey to staff for 1st and 2nd choices to be a lead pharmacist • Everyone got their 1st choice

12. Implementation Phase II: • Decentralized booklet was created by Task Team 1 – detailed plan for implementation • Lead people began compiling tips and tricks for their specific areas (MI core measures, transfer process for Rehab) to make moving from one POD to another easy, while customizing our care • Integration of staff into traditional clinical pharmacist activities (committee participation, precepting students, lectures) • Pharmacists began logging all interventions in claims management software • Worked out issues with wireless phones, order entry system access

13. Barriers to Success • Clinical Pharmacists struggled with perception that their practice was being “diluted.” The question was: do you have clinical practitioners or a clinical program? • Struggled to get nursing to call POD pharmacist instead of main department (learning curve) • Seasoned “day” pharmacists transitioning to work a few evenings each schedule, allowing evening pharmacists to participate in decentralized activities. • Several staff pharmacists still struggling with stepping outside their comfort zone and interacting on nursing units • Difficulty with wireless phones • Defining how technicians can support this new model

14. Measuring the Results • Pharmacist Survey (formal and through discussion) • Not enough time to complete all tasks! • Better relationships • Love the new model better than the old • Feel more professionally fulfilled • Nursing Survey • Pod Pharmacist is easily accessible? • Yes – 34 • No – 2 • Orders entered in a more timely fashion? • Yes – 37 • No – 3

15. Measuring the Results • Areas that have improved: • Overall consensus is that the timeliness of order entry has significantly improved as well as the medications are arriving on the floor much quicker. eMAR changes are also being completed more timely. • Easier access to pharmacists for questions and patient care issues was also a common theme. • Face to face contact has significantly improved nursing and pharmacy relations.

16. Measuring the Results • Retention of Pharmacists (varying reasons for leaving, but nonetheless, concerning) • Year Prior - 21% turnover • Implementation Year - 5% turnover

17. Turn Around Time(baseline was 45-60 minutes) • As Measured by Pharmacy: • 8-1 to 8-8 (n=75) • Mean Time: 44.3 minutes • Shortest Time: 6 minutes • Longest Time: 104 minutes • Median: 45 minutes • Std. Dev.: 16.9 minutes • As Measured by Nursing (lean project) • August (n=44) • Mean Time: 18.1 minutes • Shortest Time: 2 minutes • Longest Time: 91 minutes • Median: 15 minutes

18. Clinical Data

19. IV to PO Interventions

20. Unanticipated benefits • Issues are being addressed/resolved before management is even notified • Individual physician issues are easier to address because of relationship building on nursing units • Showcased new model by using ASHP format for customized Pharmacy Week posters

21. Future: • Nursing inservices • Increase involvement in medication reconciliation/discharge counseling • Student mentoring/precepting in focused areas (Cardiology)

22. Closing Thoughts: • When have you last shared your vision with your department? • Are you brave enough to “break the mold” so that the new can be better? • When given the chance, good pharmacists (with the desire to do more), can become great • Challenge your pharmacists to become more involved