ASHP REPORT 2004 ASHP Leadership Conference

ASHP REPORT

2004 ASHP Leadership Conference on Pharmacy

Practice Management Executive Summary:
Improving patient care and medication safety
Am J Health-Syst Pharm. 2005; 62:1303-10

E
ffective leadership stems from
core values: authenticity, cour-
age, perseverance, vision, mis-
sion, enthusiasm, focus, awareness,
service, integrity, and faith. Leader-
ship means influencing others. Effec-
tive leaders use emotion-focused
coping skills. Emotional rewards are
better motivators than monetary re-
wards. Setting goals tied to employ-
ees’ values helps motivate employees.
Leaders can create a “systems” cli-
mate that supports patient safety.
These ideas, plus the basics of
monitoring productivity, developing
ambulatory care pharmacies, com-
plying with accreditation stan-
dards, bar coding, and electronic
administration records, were pre-
sented at the Ninth Annual ASHP
Leadership Conference on Phar-
macy Practice Management. The
conference, titled “Improving Pa-
tient Care and Medication Safety,”
was held October 18–19, 2004,
in Chicago. The complete proceed-
ings of the conference are available
at www.ashp.org/practicemanager/
LeadershipDevelopment.cfm.
Joe Tye, a former health care exec-
utive and nationally recognized
speaker on effective leadership,
opened the conference by describing
core values (such as enthusiasm) that
can help an organization achieve its
desired outcomes.
David W. Bates, chief of general
internal medicine at Brigham and
Women’s Hospital, Boston, and a
leader in efforts to reduce medical
errors, reviewed ways in which infor-
mation technology can improve
medication safety.
Marv D. Shepherd, director of the
center for pharmacoeconomic stud-
ies at the University of Texas, de-
scribed the magnitude and conse-
quences of drug importation into the
United States.
Five concurrent programs were
held on Monday afternoon and re-
peated on Tuesday morning, allow-
ing each registrant to choose two
programs. The topics were bench-
marking and productivity monitor-
ing, building health-system pharma-
cy leaders, improving medication
safety through bar coding and elec-
tronic records, motivating staff to
provide quality patient care, and im-
plementing ambulatory care phar-
macy services.
Tuesday afternoon began with
Patricia C. Kienle’s strategies for
meeting new accreditation standards
and three pharmacy directors’
“pearls” from their hospitals’ 2004
surveys.
Clinical psychologist Wayne M.
Sotile wrapped up the conference
with “Leading through Uncontrolla-
ble Times.”
Values of leadership
Joe Tye outlined values-based life
and leadership skills that he calls
core action values, as well as four
“performance cornerstones” for each
value. The number one value is au-
thenticity; its cornerstones are self-
awareness, self-mastery, belief in
oneself, and being true to oneself.
Tye offered a “self-empowerment
pledge” consisting of a promise for
each day of the week. For example,
Monday’s promise is, “I will take
complete responsibility for my
health, my happiness, my success,
and my life, and will not blame oth-
ers for my problems or predica-
ments.” For the first month you will
not believe your promises, said Tye,
but the cognitive dissonance between
the empowering promise and your
limiting self-beliefs will motivate
positive action. Also use the “direc-
tion deflection question”: Is what I
am about to do or say consistent with
my ideal best self?
Using these tools requires cour-
age, or standing up to fear. Anxiety, a
generalized sense of dread rather

Planned by the ASHP Section of Pharmacy Practice Managers and Copyright © 2005, American Society of Health-System Pharma-
made possible through educational grants from Roche Pharmaceuti- cists, Inc. All rights reserved. 1079-2082/05/0602-1303$06.00.
cals, Hospira Worldwide, Inc., and Eli Lilly and Company.

Am J Health-Syst Pharm—Vol 62 Jun 15, 2005 1303

 ASHP REPORT 2004 ASHP Leadership Conference
than a specific fear, leads people to
behave inappropriately to gain a
sense of control. Leaders need to
make sure people are afraid of the
right thing (e.g., the competition, not
the boss).
Perseverance will be needed in
health care’s tough times ahead. Its
cornerstones are preparation, per-
spective, toughness, and learning.
Progress is made through “critical
mass goal achievement”; too many
people quit before reaching that crit-
ical point at which “things take off.”
To maintain perspective and resil-
ience during adversity, one should
“be thankful ahead of time” for one’s
troubles.
Getting to the critical mass re-
quires vision. A cornerstone is atten-
tion to the present; on this can be
built “memories of the future”: ex-
pecting something and working to
make it happen. Health care needs a
renewed sense of mission, a corner-
stone of which is attitude. Hospitals
have become businesses and profes-
sionals have become job oriented.
Hospitals’ attitude toward staff is too
hierarchical; people are quickly
judged on the basis of what uniform
they wear.
Managers often do not under-
stand their responsibility for pro-
moting enthusiasm, and productivity
suffers as a result. When people have
focus and gain control of their per-
sonal lives, the organization’s pro-
ductivity improves. Awareness, or
being in the present, means actively
listening and having a mind open to
opportunities.
Health care providers need to
think about service to each other, as
well as to patients and organizations.
Tye suggested the benefit of a work
environment that, like a support
group, leaves people feeling better at
the end of the day.
Humility and honesty with oneself
are cornerstones of integrity. Patients’
spiritual faith has an impact on their
outcomes, and we need to honor that
faith, not impose our own beliefs.
1304 Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
Leadership means seeing and tak-
ing opportunities to make a differ-
ence. Leaders can find the “sparkplug
people” who can act on these values
to make the organization more posi-
tive and more productive and help
achieve its desired outcomes.
Using technology to ensure
quality patient care and
medication safety
Information systems have the po-
tential to improve patient care by
linking medical knowledge and
patient-specific data and then identi-
fying options. Information technolo-
gy can prevent errors and adverse
events and can enable a more rapid
response if an adverse event occurs.
The greatest gains will be through re-
ducing medication errors, said David
Bates.
Bates described a Web-based
medication-use system at Brigham
and Women’s Hospital that gives the
prescriber relevant laboratory test re-
sults, treatment guidelines, and dos-
age algorithms. It checks for a dosage
ceiling, allergies, and drug interac-
tions. Implementation has been long
and difficult. For example, allergy
alerts were overridden 80% of the
time during a two-month period in
2002. Chart review revealed 23 ad-
verse drug effects attributable to over-
ridden alerts in 320 patients. None of
them were life-threatening or fatal,
and none were judged to be prevent-
able. But, said Bates, people are just as
likely to override something fatal as
something less dangerous. Automated
systems should use graphics to make
potentially dangerous choices look
dangerous to the user.
Individual parts of automated
medication-use systems often do not
communicate with each other, and
the systems must be closely moni-
tored. Monitoring can be done by
computers, but humans need to
evaluate the importance of the alerts
generated.
Bates discussed initiatives of the
Leapfrog Group, a coalition of the
nation’s largest employers that uses
its health care purchasing power to
encourage providers to make safety
“leaps.” The next leap is based on
safety practices identified by the
National Quality Forum; 9 of the
30 are medication-related practices
that hospitals will be expected to
implement.
Health-system management needs
to keep safety on the radar screen. A
pharmacist could serve as safety of-
ficer. Top managers should make
rounds with the patient safety team.
Leaders, including chief executive of-
ficers, should conduct a root-cause
analysis when a patient safety issue
arises. Health care organizations
need to make greater investments in
information technology. Public poli-
cy should be changed to provide in-
centives for safety practices.
In the ideal inpatient medication
system of the future, prescribers
would write orders in computerized
systems that provide feedback. Or-
ders would go directly to the phar-
macy for review. Simple orders
would be filled by automated devic-
es. Face-to-face counterdetailing
would be used for complex prob-
lems. Point-of-care delivery devices
linked to order-entry systems would
dispense medications. All drugs, pa-
tients, and personnel would be bar
coded or radiofrequency labeled.
Computerized medication adminis-
tration records and “smart” adminis-
tration devices would be used. Also,
the use of technology in outpatient
settings would have a marked impact
on prescribing and monitoring er-
rors. Meanwhile, nontechnological
improvements in safety—many of
which involve pharmacists—should
not be overlooked.
Drug importation and the
vulnerability of the
pharmaceutical supply chain
Marv Shepherd described meth-
ods of drug diversion and counter-
feiting and how these relate to im-
portation. He suggested ways to

guard against counterfeiting and
other practices that threaten the
safety of the U.S. drug distribution
system.
Over 90% of pharmaceutical
products coming into the United
States do not carry FDA-approved
labeling. Many are substandard;
some are counterfeit drugs. Counter-
feiting of both brand-name and ge-
neric products can occur in the sup-
ply of raw materials, excipients, or
active pharmaceutical ingredients or
during drug formulation or dosage
form production. Counterfeit prod-
ucts may have the correct ingredi-
ents, the wrong ingredients, no active
ingredients, insufficient or excess
quantities of active ingredients, or
fake packaging (e.g., an altered expi-
ration date). They may have been
contaminated, stored at the wrong
temperature or under other unsafe
conditions, or fraudulently or inade-
quately labeled. They may have been
withdrawn from the U.S. market or
be animal drugs not approved for
human use. Often, a counterfeit
product is mixed with the legitimate
product to confuse investigators.
Some brand-name products com-
monly counterfeited are Procrit, Lip-
itor, Serostim, Neupogen, Epogen,
Combivir, Zyprexa, Viagra, Diflucan,
and Ambien.
Importation can involve products
that have been diverted and export-
ed, products from other countries,
and products from foreign Internet
sites. Some products purchased from
purportedly Canadian Internet phar-
macies originated in other countries.
Most diversion occurs at the ware-
housing and distribution stage,
where there are many secondary
wholesalers and repackagers. Divert-
ers purchase drugs and resell them at
a profit; they may set up shell compa-
nies for this purpose. Products from
other countries may be repackaged in
United States-labeled containers.
Theft (e.g., by employees) can occur
at this stage and at consumer drug
acquisition sites (e.g., community
ASHP REPORT 2004 ASHP Leadership Conference
and hospital pharmacies, Internet
sites, and physician offices). Stolen
products are diverted to the “gray
market”; consumers may also sell on
the gray market.
Products have been diverted from
organizations that reclaim expired or
discontinued drugs for destruction.
These facilities should keep expen-
sive medications in a locked area
where no bags, purses, or backpacks
are allowed.
FDA recommends the use of co-
vert anticounterfeiting technologies
in drug packaging and labeling, as
well as chemical tags within the
product. Electronic coding enables
pharmacies to track product receipt.
Pharmacists should use only rep-
utable wholesalers and look for sub-
tle changes in product packaging and
labeling and slight differences in bot-
tle or container size. Many drug
counterfeits are identified by pa-
tients; the pharmacist should listen
for comments about differences in
taste or feel and complaints of ad-
verse effects and check patients’
progress and laboratory test values.
Any problems should be reported to
FDA and manufacturers. The public
needs to be educated about the dan-
gers of drug importation.
Benchmarking and productivity
monitoring
Productivity targets set by exter-
nal benchmarking vendors may con-
flict with the pharmacy department’s
goals of expanding clinical services
and implementing best practices for
quality and safety, said Steve Rough
and Rafael Saenz. Pharmacy direc-
tors need to understand how bench-
marking and productivity monitor-
ing can be used to support current
pharmacy operations and expansion
of services.
The questionnaires used by exter-
nal vendors to compare hospitals
cannot identify true peers. Pharmacy
directors should select 10 or 15 peers
after talking with directors at other
institutions to learn how their data
Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
are derived and whether they are tru-
ly comparable. The measures of
acuity and intensity used in bench-
marking systems are not optimal for
pharmacy, and data must be adjusted
to account for the intensity of phar-
maceutical services required. Also,
vendors should “normalize” to the
pharmacy all expenses for drugs used
within the organization, including
such things as contrast media and
anesthetic gases. Data need to be ad-
justed to separate inpatient expense
from clinic-administered medication
expense. Today’s commercially avail-
able benchmarking systems do not
effectively capture clinical activity.
Vendors use productivity ratios
(hours worked or hours paid per unit
of output, such as discharge or or-
ders processed) and cost ratios (dol-
lars per statistic, such as drug ex-
pense per admission) to measure
departmental effectiveness. Cost ratios
are crucial in selling the pharmacy’s
services to administration, but they are
flawed when reported as a percentage
of the total hospital budget. Ideally,
total patient drug cost per admission
per diagnosis-related group (DRG)
would be used along with total patient
cost per admission per DRG, with
clinical outcomes reported.
Effective use of vendors’ reports is
time-consuming and requires the
ability to run and interpret the ap-
propriate reports. Hospital data co-
ordinators can help. As an indicator
of pharmacy resources needed, re-
ports should use a pharmacy intensi-
ty index based on average drug
charge per DRG.
Operational benchmarking
should be integrated into the budget-
ing process, with a progressive plan
for improvement. Data on four or
five agreed-upon indicators should
be analyzed quarterly; all variances
should be explained and the validity
of data checked. Benchmarking ven-
dors should develop internal checks
of data reliability, as well as systems
that indicate the quality of services
provided.
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 ASHP REPORT 2004 ASHP Leadership Conference
Measuring productivity against
oneself over time is preferable to ex-
ternal benchmarking. It is more con-
trollable, but it requires an initial
commitment of resources to estab-
lish a system of measures and targets.
Having internal targets and being
able to explain variances from bud-
get are helpful in responding to con-
sultants. A balanced scorecard tracks
key metrics grouped according to a
set of broad performance areas (e.g.,
fostering growth, improving efficien-
cy). Graphical “dashboards” can be
used to reinforce key performance
areas. Pharmacy departments need
to improve their internal monitoring
systems.
Investing in the future: Building
leaders in health-system
pharmacy
Harold Godwin and Mike Sanborn
discussed the skills and traits needed
for leadership and how to identify
and nurture future leaders. As long-
time leaders in health-system phar-
macy retire, not enough new leaders
are emerging to replace them, for
several reasons: The practice of and
expectations for health-system
pharmacy are increasingly com-
plex. Downsizing and elimination
of middle management positions
jeopardize leadership development.
Pharmacy schools focus on training
clinicians and give little attention to
leadership in health-system pharma-
cy. Succession planning for pharma-
cy director positions is lacking. In-
terest in management positions is
low, in part because of inadequate
financial rewards.
Health care organizations need
leadership at all levels. Pharmacists
with leadership ability should be
identified and put in positions where
they can succeed. Both internal and
external candidates should be con-
sidered for department leadership
positions. Involvement in profes-
sional organizations, management
experience, mentoring, and residen-
cy training help develop leaders.
1306 Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
Leadership requires a vision for
the organization in 5 or 10 years, val-
ues, and the ability to motivate oth-
ers. It involves awareness of risks and
willingness to take them. Leaders
need political savvy and drive; they
need to know their environment and
how to express their ideas effectively
in it. They need self-awareness, intel-
lectual flexibility, and objectivity.
Leaders are results oriented. A leader
embraces change, challenges others
to do the same, and helps them ac-
cept change. A leader has resilience
and a focus on the long term. A lead-
er values criticism and uses feedback
to become more effective. Leaders
know when to step back because
someone else can lead better in a par-
ticular situation.
Important personal qualities for
leaders are passion, humor, empathy,
strength of character, integrity, ma-
turity, patience, wisdom, common
sense, trustworthiness, reliability,
creativity, and sensitivity. Other
qualities include commitment, effec-
tive communication, competence,
courage, servanthood (putting others
ahead of one’s personal agenda), and
desire for lifelong learning. Success-
ful leaders select good team members
and train them well.
Pharmacy leaders need to main-
tain their practice skills and keep up
with new technology and the impact
it can have on the department. Lead-
ers need to manage expectations
effectively—to aim high but expect
some setbacks and challenges. They
need to be able to think strategically
and to support the department’s and
hospital’s goals. They need to under-
stand the organization’s finances and
to manage supplies well.
Tools for identifying the strengths
and skills that make up an indi-
vidual’s leadership style include
the Myers-Briggs Type Indicator,
the Keirsey Temperament Sorter,
Strength Finders, and the concept of
framing. Using these tools with de-
partment staff and managers can
help build a cohesive organization
and find the most effective way of
operating. Many of these tools are
available on the Internet.
Improving medication safety
through bar coding
Agatha Nolen and Alicia Perry
described planning, implementation,
and monitoring of electronic med-
ication administration records
(eMARs) with bar-code technology.
Preparation for bar coding and
eMARs begins with collaborative,
interdisciplinary identification and
analysis of all components of drug
distribution and administration,
working backward from adminis-
tration to receipt of products at the
loading dock. Doing this two or
three years before implementation
allows time for improving the proc-
ess. When questions about the
medication-use system arise simulta-
neously with the challenge of “going
electronic,” the process is difficult to
manage.
Pharmacy and nursing together
need to decide on the equipment and
whether to use an integrated or non-
integrated platform. The existing
pharmacy information system can be
a starting point if that vendor has a
bedside bar-coding product. Nurses
are to prepare and scan medications
at the bedside and must be able to see
warnings on a computer screen. A
laptop computer on a pull-out shelf
of the medication cart can be used;
screen size is a limitation of hand-
held computers. Some hospitals are
moving back from automated dis-
pensing systems to cart fill distribu-
tion to better suit bar coding and
eMAR use.
Medications should not be placed
on the pharmacy shelves until each
dose is properly bar coded. The bar
code needs to be on each item (e.g.,
tablet), not on the box. The entire
pharmacy staff must know and fol-
low a quality control process. If phar-
macy incorrectly bar codes a run of
10,000 doses, there are 10,000 oppor-
tunities for error throughout the

hospital that are not apparent to the
eye. If the bar codes are correct but
not readable, nurses will lose faith in
the system.
Timely entry of orders into the
patient profile is crucial. Nurses can
enter medications when they find it
necessary, bypassing pharmacy re-
view. And nurses depend on the sys-
tem to tell them when to administer
the next dose. This means pharmacy
must carefully coordinate pharma-
ceutical care—and take major re-
sponsibility for making the system
work.
It is important to remember that
the reason for adopting the new sys-
tem is patient safety, not saving time
or costs. Challenges with bar coding
and eMARs include providing a place
for nurses to note additional infor-
mation about patient care, as they do
on paper MARs; setting up the sys-
tem for items such as sliding-scale
insulin doses; discouraging nurses’
use of work-arounds to avoid vari-
ance warnings for late doses; and
dealing with system downtime.
Before bar coding the first drug or
scanning the first patient, a hospital
should decide what to measure and
report. Percentages of doses and pa-
tients scanned should be reported.
Pharmacy and nursing leaders need
reports that show areas for improve-
ment. The reported error rate is like-
ly to increase as the new system cap-
tures previously undetected near
misses. Reports should show how
many times errors were avoided be-
cause the nurse received a variance
warning and did not administer the
dose.
Motivating staff to provide
quality patient care
Scott Mark reviewed theories of
motivation and how leaders can mo-
tivate staff to achieve department
goals. Motivating involves creating a
need or want that people will attempt
to satisfy. Leaders can control wheth-
er people feel they contribute to the
workplace (psychogenic need for sta-
ASHP REPORT 2004 ASHP Leadership Conference
tus and power), whether they feel
their actions in the workplace are
beneficial (utilitarian need), and
whether they feel appreciated (he-
donic need, or emotional benefit).
Motivation can be intrinsic (the de-
sire to perform a behavior for its own
sake) or extrinsic (seeking rewards
and avoiding punishments). Theo-
ries of motivation address both con-
tent (what needs provide individuals’
motivational energy) and process
(how and why individuals choose
one type of behavior over another to
satisfy their needs). Leaders should
think about what provides employ-
ees with feelings of belonging or job
security; they should consider not
only ways to incentivize people but
what “dissatisfiers” may need to be
removed to improve morale and
productivity.
The economic benefits of moti-
vating staff include lower costs for
recruitment and retention, fewer sick
calls, greater efficiency, and higher-
quality work. To motivate staff, man-
agers must know the employees and
their needs.
Pharmacy managers are chal-
lenged by the great diversity of their
employees, who come from many
different cultures and respond to dif-
ferent types of motivation and differ-
ent reward mechanisms. Also, differ-
ent motivators may work at different
stages of an employee’s career. Peo-
ple need to have challenging goals
set for them, to understand how
progress is measured, to receive reg-
ular feedback, and to know what in-
tensity of effort is expected.
Wayne Sotile discussed ways of
viewing motivation in the light of
what patients say about health care
providers, as well as what he has
learned from health professionals
who seek his counsel. Motivating
staff to perform is like motivating pa-
tients to use their medications prop-
erly, he said, and the primary factor
in adherence is the patient’s relation-
ship with the health care provider. As
in counseling patients, leaders
Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
should ask if staff members feel con-
fident that they can achieve their
goals and what barriers might pre-
vent it. Leaders need an attitude of
curiosity, acceptance, warmth, and
respect for differences between
themselves and individual employ-
ees; they need to recognize the validi-
ty of the other person’s way of being
and make an effort to understand
that person.
Money is not always the greatest
motivator; higher ranked on surveys
are personal satisfaction, valuing
one’s employer, helping others, and
having an employer who is support-
ive regarding personal time. Goals
for employees should be tied to
something they value. Leaders
should be precise about what they are
asking the person to do and when
and how to know when the goal is
achieved. Goals should be high but
realistic and should target perfor-
mance, not outcomes. Leaders
should periodically check on
progress toward the goals and on
workplace satisfaction.
Sotile discussed ways to under-
stand conflicts that develop as or-
ganizations change, different person-
alities, male–female differences in
communication, and the four gener-
ations in today’s workplace.
Integrating ambulatory care
pharmacy services in an evolving
health care environment
Thomas O’Brien, Kumar Maharaj,
and Timothy Warner described the
planning and implementation of
four ambulatory care pharmacies by
their health system in Rochester,
New York. The new pharmacies were
proposed as an opportunity for
Strong Health to enhance revenue
rather than reduce costs in the face of
financial pressure. The 9–18% profit
margin projected for the ambulatory
care pharmacies could support inpa-
tient clinical pharmacy programs.
The ambulatory care sites would
improve access to and communica-
tion with pharmacists for the health
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 ASHP REPORT 2004 ASHP Leadership Conference
system’s patients who have complex
medication management needs.
Nurses and case managers had been
spending an inordinate amount of
time on pharmaceutical care. For staff
and students, the pharmacies would
offer new practice opportunities.
Physical location was crucial. The
pharmacies needed to be visible, not
tucked away. Parking and access to
public transportation were impor-
tant considerations.
In addition to clinical competence
in the health system’s core areas,
pharmacists for the new sites would
need the people skills of good com-
munity pharmacists, such as ease in
talking with patients and working in
a busy environment. Although phar-
macist salaries could not be competi-
tive with those at chain stores, they
were set higher than for inpatient
pharmacists. Still, none of the health
system’s inpatient pharmacists ini-
tially wanted to work at the new sites,
and Strong recruited community
pharmacists who were attracted by
the more challenging practice setting
and more favorable schedule. Man-
agers were needed who were compe-
tent in community practice and
knew the relevant regulations.
A business plan for each site was
developed for presentation to the
health system’s administration. Cur-
rent clinic records were used to
project numbers of prescriptions and
potential revenue on the basis of net
cost and third-party reimbursement,
as well as the capture rate (how many
patients’ prescriptions would be
filled at the new pharmacies). The
business plans for the new sites speci-
fied the capture rate that would be
needed to meet revenue targets.
Analysis of revenue and costs includ-
ed start-up costs: salaries, recruit-
ment, construction, equipment, li-
censure, and inventory. Sales for the
first year, margins, and expenses
were projected. The net present value
of cash flow and the time for payback
of start-up expenses were consid-
ered. Projecting reimbursement in-
1308 Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
volved knowing the payer mix and
the average price per prescription for
the targeted population.
The health system’s ambulatory
care sites include the main outpatient
pharmacy, located in the lobby of a
750-bed teaching hospital; a phar-
macy at Strong Ties, a facility that
supports psychiatric patients living
in the community; and a satellite
pharmacy in the hospital’s infec-
tious diseases clinic that serves HIV-
positive patients. These are not-for-
profit sites and can serve only the
patients and employees of the health
system. A pharmacy is being opened
at a community health center in an
underserved area. The center oper-
ates with capitation contracts that in-
clude pharmaceuticals. Strong will
implement the pharmacy and man-
age the inventory as a contract phar-
macy, but the health center (as the
entity covered under the 340B dis-
count program) will own the drugs.
Strategies and pearls for a
successful JCAHO survey
The Joint Commission on Accred-
itation of Healthcare Organizations
(JCAHO) issued new standards for
medication management in 2004,
and United States Pharmacopeia
standards for preparation of sterile
products (contained in chapter 797
of The United States Pharmacopeia
[USP]) were enacted. Patricia Kienle,
the American Society of Health-
System Pharmacists’ representative
to the JCAHO Hospital Professional
and Technical Advisory Committee,
discussed strategies for meeting these
new standards, and three pharmacy
directors described their hospitals’
2004 JCAHO surveys.
The JCAHO accreditation process
includes self-assessment, developing
an action plan for achieving compli-
ance, and using current patients’
charts to trace care throughout the
system. Staff need to understand how
to respond to questions. Hospitals
can prepare by practicing with the
tracer method.
Pharmacy leaders should be aware
of standards in the accreditation
manual chapters on the provision of
care, treatment, and services; human
resources; organizational perfor-
mance; the environment of care; and
infection control. Surveyors are like-
ly to address medication-related na-
tional patient safety goals (NPSGs).
Unapproved abbreviations must be
eliminated; this includes the abbrevi-
ations specified by JCAHO plus
three more selected by the facility.
Pharmacists should know the facili-
ty’s procedures for meeting other
medication-related NPSGs.
The medication management
chapter addresses selection and pro-
curement (e.g., an evaluation of a
drug for formulary status must in-
clude its propensity for medication
errors, abuse, and sentinel events),
storage (medication areas must be
locked, sealed, or under constant
surveillance, and JCAHO’s definition
of medication includes items not
usually handled by pharmacists), or-
dering and transcription (a diagno-
sis, condition, or indication for each
medication ordered should be docu-
mented), preparing and dispensing
(only pharmacy should compound
sterile preparations, except in an
emergency or when the stability time
is short), administration, monitor-
ing, high-risk medications, and eval-
uation. Patient-specific information
must be available in the location
where medication management is
performed.
In addition to the accreditation
manual, pharmacy leaders should
read JCAHO’s Perspectives newslet-
ters and its Web site. They should
also read USP chapter 797 and keep
up with changes. Surveyors are ask-
ing facilities for documentation of
competence in sterile product prepa-
ration and for compliance with
media-fill testing requirements.
ASHP’s compounding resource cen-
ter on the Web includes a model “gap
analysis” for compliance with chap-
ter 797.

At Martha Jefferson Hospital in
Charlottesville, Virginia, said Janet
Silvester, surveyors using the patient
tracer process watched nurses pre-
pare and administer medications and
discuss possible effects with their pa-
tients. The pharmacy department
was called on to provide the hospi-
tal’s policy on nurses’ interpretation
of range orders. When surveyors
asked what nurses do when physi-
cians write orders for nonformulary
items or patients’ own medications, a
pharmacist was on hand to supply
the answer. Surveyors asked nurses if
they ever give medications before the
pharmacy has a chance to review
them. They asked when medications
can be given in the emergency de-
partment without pharmacy review.
Silvester strongly advised having
pharmacists available on the nursing
units during a survey.
Pharmacy newsletters helped the
hospital staff prepare for the survey,
and pharmacists conducted mock
surveys to teach nurses how to best
answer questions. Surveyors focused
on the NPSGs. In the pharmacy, they
asked about precautions for look-
alike and sound-alike drugs.
Surveyors liked the laminated lists
of unapproved abbreviations placed
in the front of paper charts. They
found that patients’ current medica-
tion regimens were not always clear.
Another finding was inadequate doc-
umentation of reassessment of pain
after analgesic administration; the
electronic documentation system
now prompts nurses to do this.
Peter Pascale, at the Erie County
Medical Center in Buffalo, New
York, conducted mock surveys of
medication management. The phar-
macy and therapeutics committee
newsletter featured the hospital’s
list of nine high-alert, high-risk
medications. The policy manual and
formulary were updated with cross-
references to the medication man-
agement standards. Pascale kept an
“evidence binder” to document ef-
forts to meet the standards.
ASHP REPORT 2004 ASHP Leadership Conference
Areas of focus during the survey
(patient tracer process) included
how changes in hematocrit affect
finger-stick blood glucose testing;
chemotherapy drug preparation,
nurses’ qualifications to administer
chemotherapy drugs, and how waste
from chemotherapy drugs is han-
dled; use of conscious sedation and
reversal agents; illegible physician
handwriting; and pain management
in cognitively impaired patients. In
the pharmacy, the surveyors asked
about risk assessment or gap analysis
regarding chapter 797. They looked
at the storage of expired medications
and asked about the handling of drug
samples and who approved their use,
and they asked how often clinical up-
dates were entered into the pharmacy
information system.
In a system tracer for medication
management, the pharmacy was
asked about the formulary review
process; how adverse drug reactions,
medication errors, and root-cause
analysis are handled; and how the
literature is used to improve the
safety of medication use. The survey-
ors reviewed policy in several areas,
including overrides of unit-based
cabinets.
In 2004 facilities were not yet re-
quired to be in compliance with
chapter 797 as long as they had plans
for doing so, said Michael Sovie of
Cardinal Health/St. Lucie Medical
Center in Florida. Yet the hospital
was cited for noncompliance with
chapter 797. Knowing that the need-
ed structural changes could not be
completed before the survey, phar-
macy managers had decided to con-
centrate on updating sterile prepara-
tion policies and procedures and
educating staff. An i.v. room com-
mittee was established to give the
staff ownership of a process that will
mean many changes. A hood certifier
tested the air quality and provided a
report. Architectural assessment and
planning began.
Sovie said that, although survey-
ors need a better understanding of
Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
the timeline for compliance with
chapter 797, the criticisms helped
make pharmacy’s case to hospital
administration about the new re-
quirements for sterile product prepa-
ration and their implications for
accreditation.
Leading through uncontrollable
times
Effective leaders use emotion-
focused coping skills, Wayne Sotile
said in his closing presentation.
Burnout accounts for 40% of worker
turnover, and stress-related costs to
U.S. companies each year total $300
billion. Burnout is characterized by
emotional exhaustion. People start
resenting the routine demands
that come with their roles at work
and at home. Their actions become
inconsistent with their core values,
and their relationships deteriorate.
They have a diminished sense of per-
sonal accomplishment. When once-
energized workers are worn down
and burned out, organizations suffer.
Fewer than 30% of workers are fully
engaged, and the disengaged spread
negative emotions.
The key to avoiding burnout is re-
silience. People who are the healthi-
est and happiest report the most
satisfaction with their job or career.
Satisfaction in the workplace comes
with teamwork, which is dependent
on retaining workers. The leader’s
degree of happiness creates the con-
text that either recruits and retains
staff or drives people away. Resilient
people love their work and their per-
sonal lives.
Keeping pharmacists more fully
engaged will contribute to job satis-
faction and interest in leadership.
Pharmacists a few years into their ca-
reers may feel cheated when the
services they offer are not as highly
valued as they had expected; for ex-
ample, patients challenge advice with
information gleaned from the Inter-
net and other sources. The effect of
job stress onvb pharmacists depends
on commitment to their careers,
1309
 ASHP REPORT 2004 ASHP Leadership Conference
support from their organizations,
and balance between their expecta-
tions and achievements.
The worker’s relationship with the
boss is the largest determinant of sat-
isfaction. Across industries, the chief
reason for leaving a job is limited
praise and recognition. Successful
leaders and stress managers create a
positive interpersonal culture. They
have internal fortitude, a sense of hu-
mor, belief in something larger than
themselves, and, most important,
caring connections with other peo-
ple. They are externally oriented, for-
giving, open to learning about oth-
ers, and humble.
Good leaders accept responsibility
for poor results without feeling de-
feated. They never blame others.
They recognize the contributions of
others and do not shine the spotlight
on themselves. If you want to be a
great leader, said Sotile, you have to
be a hero for the people you deal
with: one who creates safe spaces for
other people.
Spreading recognition and praise
boosts productivity, mood, engage-
ment, retention, loyalty, satisfaction,
and safety. Successful leaders take an
interest in individuals’ talents, goals,
and families, and the employees val-
ue the feeling of being known.
Leaders need realistic optimism:
seeing the world as it is but working
positively toward a desired outcome.
The key to resilience in the face of
stress is not eliminating all day-to-
day hassles but making sure there are
positive forces to counteract the neg-
atives. Leaders need to be spreaders
of positivity, and they can do this
only if they guard against burnout in
their own lives.
1310 Am J Health-Syst Pharm—Vol 62 Jun 15, 2005
Programs and Presenters
Twelve Values of Leadership
Joe Tye, M.B.A.
“America’s Values Coach”
Five Star Speakers & Trainers
Overland Park, KS
Using Technology To Ensure Quality Patient
Care and Medication Safety
David W. Bates, M.D., M.Sc.
Chief, General Medicine Division
Brigham and Women’s Hospital
Professor of Medicine
Harvard Medical School
Boston, MA
Drug Importation and the Vulnerability of
Our Pharmaceutical Supply Chain
Marv D. Shepherd, Ph.D.
Director, Center for Pharmacoeconomic
Studies
University of Texas
Austin, TX
Benchmarking and Productivity Monitoring:
Practical Strategies for Pharmacy Managers
Steve Rough, M.S.
Director of Pharmacy
University of Wisconsin Hospital and
Clinics
Clinical Assistant Professor
School of Pharmacy
University of Wisconsin
Madison, WI
Rafael Saenz, Pharm.D.
Administrative Pharmacy Resident
University of Wisconsin Hospital and
Clinics
Madison, WI
Investing in the Future: Building Leaders in
Health-System Pharmacy
Harold N. Godwin, M.S., FASHP
Professor and Chair, Department of
Pharmacy Practice
School of Pharmacy
University of Kansas
Kansas City, KS
Mike D. Sanborn, M.S.
Director of Pharmacy Services
Baylor Healthcare System
Dallas, TX
Improving Medication Safety through Bar
Coding
Agatha L. Nolen, M.S., D.Ph., FASHP
Director of Pharmacy
Centennial Medical Center
Nashville, TN
Alicia B. Perry, Pharm.D.
Assistant Vice President, Patient Safety
Hospital Corporation of America
Corporate Quality Department
Nashville, TN
Motivating Staff To Provide Quality Patient
Care
Scott M. Mark, Pharm.D., M.S., FASHP
Director of Pharmacy
Children’s National Medical Center
Washington, DC
Wayne M. Sotile, Ph.D.
Director of Psychological Services
Wake Forest University
Cardiac Rehabilitation Program Co-
Director
Sotile Psychological Associates and Real
Talk, Inc.
Winston-Salem, NC
Integrating Ambulatory Care Pharmacy
Services in an Evolving Health Care
Environment
Thomas E. O’Brien, Pharm.D.
Director of Pharmacy–Strong Health
University of Rochester Medical Center
Rochester, NY
Kumar Maharaj, M.S.B.A., FASCP, BCCP
Supervising Pharmacist
Strong Ties Pharmacy
University of Rochester Medical Center
Rochester, NY
Timothy J. Warner
Ambulatory Pharmacy Manager
University of Rochester Medical Center
Rochester, NY
Strategies and Pearls for a Successful JCAHO
Survey
Patricia C. Kienle, M.P.A., FASHP
Operations Director for Accreditation and
Medication Safety
Cardinal Health Pharmacy Management
Laflin, PA
Janet Silvester, M.B.A., FASHP
Director of Pharmacy Services
Martha Jefferson Hospital
Charlottesville, VA
Peter M. Pascale, M.S., FASHP
Director of Pharmacy
Erie County Medical Center
Buffalo, NY
Michael J. Sovie, Pharm.D., M.B.A.
Director of Pharmacy
Cardinal Health/St. Lucie Medical Center
St. Lucie, FL
Leading through Uncontrollable Times
Wayne M. Sotile
Moderator
Scott M. Mark
Chair, ASHP Section of Pharmacy Practice
Managers