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

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ASHP REPORT 2004 ASHP Leadership Conference

than a specific fear, leads people to Leadership means seeing and tak- nation’s largest employers that uses
behave inappropriately to gain a ing opportunities to make a differ- its health care purchasing power to
sense of control. Leaders need to ence. Leaders can find the “sparkplug encourage providers to make safety
make sure people are afraid of the people” who can act on these values “leaps.” The next leap is based on
right thing (e.g., the competition, not to make the organization more posi- safety practices identified by the
the boss). tive and more productive and help National Quality Forum; 9 of the
Perseverance will be needed in achieve its desired outcomes. 30 are medication-related practices
health care’s tough times ahead. Its that hospitals will be expected to
cornerstones are preparation, per- Using technology to ensure implement.
spective, toughness, and learning. quality patient care and Health-system management needs
Progress is made through “critical medication safety to keep safety on the radar screen. A
mass goal achievement”; too many Information systems have the po- pharmacist could serve as safety of-
people quit before reaching that crit- tential to improve patient care by ficer. Top managers should make
ical point at which “things take off.” linking medical knowledge and rounds with the patient safety team.
To maintain perspective and resil- patient-specific data and then identi- Leaders, including chief executive of-
ience during adversity, one should fying options. Information technolo- ficers, should conduct a root-cause
“be thankful ahead of time” for one’s gy can prevent errors and adverse analysis when a patient safety issue
troubles. events and can enable a more rapid arises. Health care organizations
Getting to the critical mass re- response if an adverse event occurs. need to make greater investments in
quires vision. A cornerstone is atten- The greatest gains will be through re- information technology. Public poli-
tion to the present; on this can be ducing medication errors, said David cy should be changed to provide in-
built “memories of the future”: ex- Bates. centives for safety practices.
pecting something and working to Bates described a Web-based In the ideal inpatient medication
make it happen. Health care needs a medication-use system at Brigham system of the future, prescribers
renewed sense of mission, a corner- and Women’s Hospital that gives the would write orders in computerized
stone of which is attitude. Hospitals prescriber relevant laboratory test re- systems that provide feedback. Or-
have become businesses and profes- sults, treatment guidelines, and dos- ders would go directly to the phar-
sionals have become job oriented. age algorithms. It checks for a dosage macy for review. Simple orders
Hospitals’ attitude toward staff is too ceiling, allergies, and drug interac- would be filled by automated devic-
hierarchical; people are quickly tions. Implementation has been long es. Face-to-face counterdetailing
judged on the basis of what uniform and difficult. For example, allergy would be used for complex prob-
they wear. alerts were overridden 80% of the lems. Point-of-care delivery devices
Managers often do not under- time during a two-month period in linked to order-entry systems would
stand their responsibility for pro- 2002. Chart review revealed 23 ad- dispense medications. All drugs, pa-
moting enthusiasm, and productivity verse drug effects attributable to over- tients, and personnel would be bar
suffers as a result. When people have ridden alerts in 320 patients. None of coded or radiofrequency labeled.
focus and gain control of their per- them were life-threatening or fatal, Computerized medication adminis-
sonal lives, the organization’s pro- and none were judged to be prevent- tration records and “smart” adminis-
ductivity improves. Awareness, or able. But, said Bates, people are just as tration devices would be used. Also,
being in the present, means actively likely to override something fatal as the use of technology in outpatient
listening and having a mind open to something less dangerous. Automated settings would have a marked impact
opportunities. systems should use graphics to make on prescribing and monitoring er-
Health care providers need to potentially dangerous choices look rors. Meanwhile, nontechnological
think about service to each other, as dangerous to the user. improvements in safety—many of
well as to patients and organizations. Individual parts of automated which involve pharmacists—should
Tye suggested the benefit of a work medication-use systems often do not not be overlooked.
environment that, like a support communicate with each other, and
group, leaves people feeling better at the systems must be closely moni- Drug importation and the
the end of the day. tored. Monitoring can be done by vulnerability of the
Humility and honesty with oneself computers, but humans need to pharmaceutical supply chain
are cornerstones of integrity. Patients’ evaluate the importance of the alerts Marv Shepherd described meth-
spiritual faith has an impact on their generated. ods of drug diversion and counter-
outcomes, and we need to honor that Bates discussed initiatives of the feiting and how these relate to im-
faith, not impose our own beliefs. Leapfrog Group, a coalition of the portation. He suggested ways to

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ASHP REPORT 2004 ASHP Leadership Conference

guard against counterfeiting and and hospital pharmacies, Internet are derived and whether they are tru-
other practices that threaten the sites, and physician offices). Stolen ly comparable. The measures of
safety of the U.S. drug distribution products are diverted to the “gray acuity and intensity used in bench-
system. market”; consumers may also sell on marking systems are not optimal for
Over 90% of pharmaceutical the gray market. pharmacy, and data must be adjusted
products coming into the United Products have been diverted from to account for the intensity of phar-
States do not carry FDA-approved organizations that reclaim expired or maceutical services required. Also,
labeling. Many are substandard; discontinued drugs for destruction. vendors should “normalize” to the
some are counterfeit drugs. Counter- These facilities should keep expen- pharmacy all expenses for drugs used
feiting of both brand-name and ge- sive medications in a locked area within the organization, including
neric products can occur in the sup- where no bags, purses, or backpacks such things as contrast media and
ply of raw materials, excipients, or are allowed. anesthetic gases. Data need to be ad-
active pharmaceutical ingredients or FDA recommends the use of co- justed to separate inpatient expense
during drug formulation or dosage vert anticounterfeiting technologies from clinic-administered medication
form production. Counterfeit prod- in drug packaging and labeling, as expense. Today’s commercially avail-
ucts may have the correct ingredi- well as chemical tags within the able benchmarking systems do not
ents, the wrong ingredients, no active product. Electronic coding enables effectively capture clinical activity.
ingredients, insufficient or excess pharmacies to track product receipt. Vendors use productivity ratios
quantities of active ingredients, or Pharmacists should use only rep- (hours worked or hours paid per unit
fake packaging (e.g., an altered expi- utable wholesalers and look for sub- of output, such as discharge or or-
ration date). They may have been tle changes in product packaging and ders processed) and cost ratios (dol-
contaminated, stored at the wrong labeling and slight differences in bot- lars per statistic, such as drug ex-
temperature or under other unsafe tle or container size. Many drug pense per admission) to measure
conditions, or fraudulently or inade- counterfeits are identified by pa- departmental effectiveness. Cost ratios
quately labeled. They may have been tients; the pharmacist should listen are crucial in selling the pharmacy’s
withdrawn from the U.S. market or for comments about differences in services to administration, but they are
be animal drugs not approved for taste or feel and complaints of ad- flawed when reported as a percentage
human use. Often, a counterfeit verse effects and check patients’ of the total hospital budget. Ideally,
product is mixed with the legitimate progress and laboratory test values. total patient drug cost per admission
product to confuse investigators. Any problems should be reported to per diagnosis-related group (DRG)
Some brand-name products com- FDA and manufacturers. The public would be used along with total patient
monly counterfeited are Procrit, Lip- needs to be educated about the dan- cost per admission per DRG, with
itor, Serostim, Neupogen, Epogen, gers of drug importation. clinical outcomes reported.
Combivir, Zyprexa, Viagra, Diflucan, Effective use of vendors’ reports is
and Ambien. Benchmarking and productivity time-consuming and requires the
Importation can involve products monitoring ability to run and interpret the ap-
that have been diverted and export- Productivity targets set by exter- propriate reports. Hospital data co-
ed, products from other countries, nal benchmarking vendors may con- ordinators can help. As an indicator
and products from foreign Internet flict with the pharmacy department’s of pharmacy resources needed, re-
sites. Some products purchased from goals of expanding clinical services ports should use a pharmacy intensi-
purportedly Canadian Internet phar- and implementing best practices for ty index based on average drug
macies originated in other countries. quality and safety, said Steve Rough charge per DRG.
Most diversion occurs at the ware- and Rafael Saenz. Pharmacy direc- Operational benchmarking
housing and distribution stage, tors need to understand how bench- should be integrated into the budget-
where there are many secondary marking and productivity monitor- ing process, with a progressive plan
wholesalers and repackagers. Divert- ing can be used to support current for improvement. Data on four or
ers purchase drugs and resell them at pharmacy operations and expansion five agreed-upon indicators should
a profit; they may set up shell compa- of services. be analyzed quarterly; all variances
nies for this purpose. Products from The questionnaires used by exter- should be explained and the validity
other countries may be repackaged in nal vendors to compare hospitals of data checked. Benchmarking ven-
United States-labeled containers. cannot identify true peers. Pharmacy dors should develop internal checks
Theft (e.g., by employees) can occur directors should select 10 or 15 peers of data reliability, as well as systems
at this stage and at consumer drug after talking with directors at other that indicate the quality of services
acquisition sites (e.g., community institutions to learn how their data provided.

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Measuring productivity against Leadership requires a vision for and find the most effective way of
oneself over time is preferable to ex- the organization in 5 or 10 years, val- operating. Many of these tools are
ternal benchmarking. It is more con- ues, and the ability to motivate oth- available on the Internet.
trollable, but it requires an initial ers. It involves awareness of risks and
commitment of resources to estab- willingness to take them. Leaders Improving medication safety
lish a system of measures and targets. need political savvy and drive; they through bar coding
Having internal targets and being need to know their environment and Agatha Nolen and Alicia Perry
able to explain variances from bud- how to express their ideas effectively described planning, implementation,
get are helpful in responding to con- in it. They need self-awareness, intel- and monitoring of electronic med-
sultants. A balanced scorecard tracks lectual flexibility, and objectivity. ication administration records
key metrics grouped according to a Leaders are results oriented. A leader (eMARs) with bar-code technology.
set of broad performance areas (e.g., embraces change, challenges others Preparation for bar coding and
fostering growth, improving efficien- to do the same, and helps them ac- eMARs begins with collaborative,
cy). Graphical “dashboards” can be cept change. A leader has resilience interdisciplinary identification and
used to reinforce key performance and a focus on the long term. A lead- analysis of all components of drug
areas. Pharmacy departments need er values criticism and uses feedback distribution and administration,
to improve their internal monitoring to become more effective. Leaders working backward from adminis-
systems. know when to step back because tration to receipt of products at the
someone else can lead better in a par- loading dock. Doing this two or
Investing in the future: Building ticular situation. three years before implementation
leaders in health-system Important personal qualities for allows time for improving the proc-
pharmacy leaders are passion, humor, empathy, ess. When questions about the
Harold Godwin and Mike Sanborn strength of character, integrity, ma- medication-use system arise simulta-
discussed the skills and traits needed turity, patience, wisdom, common neously with the challenge of “going
for leadership and how to identify sense, trustworthiness, reliability, electronic,” the process is difficult to
and nurture future leaders. As long- creativity, and sensitivity. Other manage.
time leaders in health-system phar- qualities include commitment, effec- Pharmacy and nursing together
macy retire, not enough new leaders tive communication, competence, need to decide on the equipment and
are emerging to replace them, for courage, servanthood (putting others whether to use an integrated or non-
several reasons: The practice of and ahead of one’s personal agenda), and integrated platform. The existing
expectations for health-system desire for lifelong learning. Success- pharmacy information system can be
pharmacy are increasingly com- ful leaders select good team members a starting point if that vendor has a
plex. Downsizing and elimination and train them well. bedside bar-coding product. Nurses
of middle management positions Pharmacy leaders need to main- are to prepare and scan medications
jeopardize leadership development. tain their practice skills and keep up at the bedside and must be able to see
Pharmacy schools focus on training with new technology and the impact warnings on a computer screen. A
clinicians and give little attention to it can have on the department. Lead- laptop computer on a pull-out shelf
leadership in health-system pharma- ers need to manage expectations of the medication cart can be used;
cy. Succession planning for pharma- effectively—to aim high but expect screen size is a limitation of hand-
cy director positions is lacking. In- some setbacks and challenges. They held computers. Some hospitals are
terest in management positions is need to be able to think strategically moving back from automated dis-
low, in part because of inadequate and to support the department’s and pensing systems to cart fill distribu-
financial rewards. hospital’s goals. They need to under- tion to better suit bar coding and
Health care organizations need stand the organization’s finances and eMAR use.
leadership at all levels. Pharmacists to manage supplies well. Medications should not be placed
with leadership ability should be Tools for identifying the strengths on the pharmacy shelves until each
identified and put in positions where and skills that make up an indi- dose is properly bar coded. The bar
they can succeed. Both internal and vidual’s leadership style include code needs to be on each item (e.g.,
external candidates should be con- the Myers-Briggs Type Indicator, tablet), not on the box. The entire
sidered for department leadership the Keirsey Temperament Sorter, pharmacy staff must know and fol-
positions. Involvement in profes- Strength Finders, and the concept of low a quality control process. If phar-
sional organizations, management framing. Using these tools with de- macy incorrectly bar codes a run of
experience, mentoring, and residen- partment staff and managers can 10,000 doses, there are 10,000 oppor-
cy training help develop leaders. help build a cohesive organization tunities for error throughout the

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ASHP REPORT 2004 ASHP Leadership Conference

hospital that are not apparent to the tus and power), whether they feel should ask if staff members feel con-
eye. If the bar codes are correct but their actions in the workplace are fident that they can achieve their
not readable, nurses will lose faith in beneficial (utilitarian need), and goals and what barriers might pre-
the system. whether they feel appreciated (he- vent it. Leaders need an attitude of
Timely entry of orders into the donic need, or emotional benefit). curiosity, acceptance, warmth, and
patient profile is crucial. Nurses can Motivation can be intrinsic (the de- respect for differences between
enter medications when they find it sire to perform a behavior for its own themselves and individual employ-
necessary, bypassing pharmacy re- sake) or extrinsic (seeking rewards ees; they need to recognize the validi-
view. And nurses depend on the sys- and avoiding punishments). Theo- ty of the other person’s way of being
tem to tell them when to administer ries of motivation address both con- and make an effort to understand
the next dose. This means pharmacy tent (what needs provide individuals’ that person.
must carefully coordinate pharma- motivational energy) and process Money is not always the greatest
ceutical care—and take major re- (how and why individuals choose motivator; higher ranked on surveys
sponsibility for making the system one type of behavior over another to are personal satisfaction, valuing
work. satisfy their needs). Leaders should one’s employer, helping others, and
It is important to remember that think about what provides employ- having an employer who is support-
the reason for adopting the new sys- ees with feelings of belonging or job ive regarding personal time. Goals
tem is patient safety, not saving time security; they should consider not for employees should be tied to
or costs. Challenges with bar coding only ways to incentivize people but something they value. Leaders
and eMARs include providing a place what “dissatisfiers” may need to be should be precise about what they are
for nurses to note additional infor- removed to improve morale and asking the person to do and when
mation about patient care, as they do productivity. and how to know when the goal is
on paper MARs; setting up the sys- The economic benefits of moti- achieved. Goals should be high but
tem for items such as sliding-scale vating staff include lower costs for realistic and should target perfor-
insulin doses; discouraging nurses’ recruitment and retention, fewer sick mance, not outcomes. Leaders
use of work-arounds to avoid vari- calls, greater efficiency, and higher- should periodically check on
ance warnings for late doses; and quality work. To motivate staff, man- progress toward the goals and on
dealing with system downtime. agers must know the employees and workplace satisfaction.
Before bar coding the first drug or their needs. Sotile discussed ways to under-
scanning the first patient, a hospital Pharmacy managers are chal- stand conflicts that develop as or-
should decide what to measure and lenged by the great diversity of their ganizations change, different person-
report. Percentages of doses and pa- employees, who come from many alities, male–female differences in
tients scanned should be reported. different cultures and respond to dif- communication, and the four gener-
Pharmacy and nursing leaders need ferent types of motivation and differ- ations in today’s workplace.
reports that show areas for improve- ent reward mechanisms. Also, differ-
ment. The reported error rate is like- ent motivators may work at different Integrating ambulatory care
ly to increase as the new system cap- stages of an employee’s career. Peo- pharmacy services in an evolving
tures previously undetected near ple need to have challenging goals health care environment
misses. Reports should show how set for them, to understand how Thomas O’Brien, Kumar Maharaj,
many times errors were avoided be- progress is measured, to receive reg- and Timothy Warner described the
cause the nurse received a variance ular feedback, and to know what in- planning and implementation of
warning and did not administer the tensity of effort is expected. four ambulatory care pharmacies by
dose. Wayne Sotile discussed ways of their health system in Rochester,
viewing motivation in the light of New York. The new pharmacies were
Motivating staff to provide what patients say about health care proposed as an opportunity for
quality patient care providers, as well as what he has Strong Health to enhance revenue
Scott Mark reviewed theories of learned from health professionals rather than reduce costs in the face of
motivation and how leaders can mo- who seek his counsel. Motivating financial pressure. The 9–18% profit
tivate staff to achieve department staff to perform is like motivating pa- margin projected for the ambulatory
goals. Motivating involves creating a tients to use their medications prop- care pharmacies could support inpa-
need or want that people will attempt erly, he said, and the primary factor tient clinical pharmacy programs.
to satisfy. Leaders can control wheth- in adherence is the patient’s relation- The ambulatory care sites would
er people feel they contribute to the ship with the health care provider. As improve access to and communica-
workplace (psychogenic need for sta- in counseling patients, leaders tion with pharmacists for the health

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ASHP REPORT 2004 ASHP Leadership Conference

system’s patients who have complex volved knowing the payer mix and Pharmacy leaders should be aware
medication management needs. the average price per prescription for of standards in the accreditation
Nurses and case managers had been the targeted population. manual chapters on the provision of
spending an inordinate amount of The health system’s ambulatory care, treatment, and services; human
time on pharmaceutical care. For staff care sites include the main outpatient resources; organizational perfor-
and students, the pharmacies would pharmacy, located in the lobby of a mance; the environment of care; and
offer new practice opportunities. 750-bed teaching hospital; a phar- infection control. Surveyors are like-
Physical location was crucial. The macy at Strong Ties, a facility that ly to address medication-related na-
pharmacies needed to be visible, not supports psychiatric patients living tional patient safety goals (NPSGs).
tucked away. Parking and access to in the community; and a satellite Unapproved abbreviations must be
public transportation were impor- pharmacy in the hospital’s infec- eliminated; this includes the abbrevi-
tant considerations. tious diseases clinic that serves HIV- ations specified by JCAHO plus
In addition to clinical competence positive patients. These are not-for- three more selected by the facility.
in the health system’s core areas, profit sites and can serve only the Pharmacists should know the facili-
pharmacists for the new sites would patients and employees of the health ty’s procedures for meeting other
need the people skills of good com- system. A pharmacy is being opened medication-related NPSGs.
munity pharmacists, such as ease in at a community health center in an The medication management
talking with patients and working in underserved area. The center oper- chapter addresses selection and pro-
a busy environment. Although phar- ates with capitation contracts that in- curement (e.g., an evaluation of a
macist salaries could not be competi- clude pharmaceuticals. Strong will drug for formulary status must in-
tive with those at chain stores, they implement the pharmacy and man- clude its propensity for medication
were set higher than for inpatient age the inventory as a contract phar- errors, abuse, and sentinel events),
pharmacists. Still, none of the health macy, but the health center (as the storage (medication areas must be
system’s inpatient pharmacists ini- entity covered under the 340B dis- locked, sealed, or under constant
tially wanted to work at the new sites, count program) will own the drugs. surveillance, and JCAHO’s definition
and Strong recruited community of medication includes items not
pharmacists who were attracted by Strategies and pearls for a usually handled by pharmacists), or-
the more challenging practice setting successful JCAHO survey dering and transcription (a diagno-
and more favorable schedule. Man- The Joint Commission on Accred- sis, condition, or indication for each
agers were needed who were compe- itation of Healthcare Organizations medication ordered should be docu-
tent in community practice and (JCAHO) issued new standards for mented), preparing and dispensing
knew the relevant regulations. medication management in 2004, (only pharmacy should compound
A business plan for each site was and United States Pharmacopeia sterile preparations, except in an
developed for presentation to the standards for preparation of sterile emergency or when the stability time
health system’s administration. Cur- products (contained in chapter 797 is short), administration, monitor-
rent clinic records were used to of The United States Pharmacopeia ing, high-risk medications, and eval-
project numbers of prescriptions and [USP]) were enacted. Patricia Kienle, uation. Patient-specific information
potential revenue on the basis of net the American Society of Health- must be available in the location
cost and third-party reimbursement, System Pharmacists’ representative where medication management is
as well as the capture rate (how many to the JCAHO Hospital Professional performed.
patients’ prescriptions would be and Technical Advisory Committee, In addition to the accreditation
filled at the new pharmacies). The discussed strategies for meeting these manual, pharmacy leaders should
business plans for the new sites speci- new standards, and three pharmacy read JCAHO’s Perspectives newslet-
fied the capture rate that would be directors described their hospitals’ ters and its Web site. They should
needed to meet revenue targets. 2004 JCAHO surveys. also read USP chapter 797 and keep
Analysis of revenue and costs includ- The JCAHO accreditation process up with changes. Surveyors are ask-
ed start-up costs: salaries, recruit- includes self-assessment, developing ing facilities for documentation of
ment, construction, equipment, li- an action plan for achieving compli- competence in sterile product prepa-
censure, and inventory. Sales for the ance, and using current patients’ ration and for compliance with
first year, margins, and expenses charts to trace care throughout the media-fill testing requirements.
were projected. The net present value system. Staff need to understand how ASHP’s compounding resource cen-
of cash flow and the time for payback to respond to questions. Hospitals ter on the Web includes a model “gap
of start-up expenses were consid- can prepare by practicing with the analysis” for compliance with chap-
ered. Projecting reimbursement in- tracer method. ter 797.

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At Martha Jefferson Hospital in Areas of focus during the survey the timeline for compliance with
Charlottesville, Virginia, said Janet (patient tracer process) included chapter 797, the criticisms helped
Silvester, surveyors using the patient how changes in hematocrit affect make pharmacy’s case to hospital
tracer process watched nurses pre- finger-stick blood glucose testing; administration about the new re-
pare and administer medications and chemotherapy drug preparation, quirements for sterile product prepa-
discuss possible effects with their pa- nurses’ qualifications to administer ration and their implications for
tients. The pharmacy department chemotherapy drugs, and how waste accreditation.
was called on to provide the hospi- from chemotherapy drugs is han-
tal’s policy on nurses’ interpretation dled; use of conscious sedation and Leading through uncontrollable
of range orders. When surveyors reversal agents; illegible physician times
asked what nurses do when physi- handwriting; and pain management Effective leaders use emotion-
cians write orders for nonformulary in cognitively impaired patients. In focused coping skills, Wayne Sotile
items or patients’ own medications, a the pharmacy, the surveyors asked said in his closing presentation.
pharmacist was on hand to supply about risk assessment or gap analysis Burnout accounts for 40% of worker
the answer. Surveyors asked nurses if regarding chapter 797. They looked turnover, and stress-related costs to
they ever give medications before the at the storage of expired medications U.S. companies each year total $300
pharmacy has a chance to review and asked about the handling of drug billion. Burnout is characterized by
them. They asked when medications samples and who approved their use, emotional exhaustion. People start
can be given in the emergency de- and they asked how often clinical up- resenting the routine demands
partment without pharmacy review. dates were entered into the pharmacy that come with their roles at work
Silvester strongly advised having information system. and at home. Their actions become
pharmacists available on the nursing In a system tracer for medication inconsistent with their core values,
units during a survey. management, the pharmacy was and their relationships deteriorate.
Pharmacy newsletters helped the asked about the formulary review They have a diminished sense of per-
hospital staff prepare for the survey, process; how adverse drug reactions, sonal accomplishment. When once-
and pharmacists conducted mock medication errors, and root-cause energized workers are worn down
surveys to teach nurses how to best analysis are handled; and how the and burned out, organizations suffer.
answer questions. Surveyors focused literature is used to improve the Fewer than 30% of workers are fully
on the NPSGs. In the pharmacy, they safety of medication use. The survey- engaged, and the disengaged spread
asked about precautions for look- ors reviewed policy in several areas, negative emotions.
alike and sound-alike drugs. including overrides of unit-based The key to avoiding burnout is re-
Surveyors liked the laminated lists cabinets. silience. People who are the healthi-
of unapproved abbreviations placed In 2004 facilities were not yet re- est and happiest report the most
in the front of paper charts. They quired to be in compliance with satisfaction with their job or career.
found that patients’ current medica- chapter 797 as long as they had plans Satisfaction in the workplace comes
tion regimens were not always clear. for doing so, said Michael Sovie of with teamwork, which is dependent
Another finding was inadequate doc- Cardinal Health/St. Lucie Medical on retaining workers. The leader’s
umentation of reassessment of pain Center in Florida. Yet the hospital degree of happiness creates the con-
after analgesic administration; the was cited for noncompliance with text that either recruits and retains
electronic documentation system chapter 797. Knowing that the need- staff or drives people away. Resilient
now prompts nurses to do this. ed structural changes could not be people love their work and their per-
Peter Pascale, at the Erie County completed before the survey, phar- sonal lives.
Medical Center in Buffalo, New macy managers had decided to con- Keeping pharmacists more fully
York, conducted mock surveys of centrate on updating sterile prepara- engaged will contribute to job satis-
medication management. The phar- tion policies and procedures and faction and interest in leadership.
macy and therapeutics committee educating staff. An i.v. room com- Pharmacists a few years into their ca-
newsletter featured the hospital’s mittee was established to give the reers may feel cheated when the
list of nine high-alert, high-risk staff ownership of a process that will services they offer are not as highly
medications. The policy manual and mean many changes. A hood certifier valued as they had expected; for ex-
formulary were updated with cross- tested the air quality and provided a ample, patients challenge advice with
references to the medication man- report. Architectural assessment and information gleaned from the Inter-
agement standards. Pascale kept an planning began. net and other sources. The effect of
“evidence binder” to document ef- Sovie said that, although survey- job stress onvb pharmacists depends
forts to meet the standards. ors need a better understanding of on commitment to their careers,

Am J Health-Syst Pharm—Vol 62 Jun 15, 2005 1309


ASHP REPORT 2004 ASHP Leadership Conference

support from their organizations,


and balance between their expecta- Programs and Presenters
tions and achievements. Twelve Values of Leadership Motivating Staff To Provide Quality Patient
The worker’s relationship with the Joe Tye, M.B.A. Care
boss is the largest determinant of sat- “America’s Values Coach” Scott M. Mark, Pharm.D., M.S., FASHP
Five Star Speakers & Trainers Director of Pharmacy
isfaction. Across industries, the chief Overland Park, KS Children’s National Medical Center
reason for leaving a job is limited Using Technology To Ensure Quality Patient Washington, DC
praise and recognition. Successful Care and Medication Safety
David W. Bates, M.D., M.Sc. Wayne M. Sotile, Ph.D.
leaders and stress managers create a Chief, General Medicine Division Director of Psychological Services
positive interpersonal culture. They Brigham and Women’s Hospital Wake Forest University
have internal fortitude, a sense of hu- Professor of Medicine Cardiac Rehabilitation Program Co-
Harvard Medical School Director
mor, belief in something larger than Boston, MA Sotile Psychological Associates and Real
themselves, and, most important, Drug Importation and the Vulnerability of Talk, Inc.
caring connections with other peo- Our Pharmaceutical Supply Chain Winston-Salem, NC
Marv D. Shepherd, Ph.D. Integrating Ambulatory Care Pharmacy
ple. They are externally oriented, for- Director, Center for Pharmacoeconomic Services in an Evolving Health Care
giving, open to learning about oth- Studies Environment
ers, and humble. University of Texas Thomas E. O’Brien, Pharm.D.
Austin, TX Director of Pharmacy–Strong Health
Good leaders accept responsibility Benchmarking and Productivity Monitoring: University of Rochester Medical Center
for poor results without feeling de- Practical Strategies for Pharmacy Managers Rochester, NY
feated. They never blame others. Steve Rough, M.S.
Director of Pharmacy Kumar Maharaj, M.S.B.A., FASCP, BCCP
They recognize the contributions of University of Wisconsin Hospital and Supervising Pharmacist
others and do not shine the spotlight Clinics Strong Ties Pharmacy
on themselves. If you want to be a Clinical Assistant Professor University of Rochester Medical Center
School of Pharmacy Rochester, NY
great leader, said Sotile, you have to University of Wisconsin
be a hero for the people you deal Madison, WI Timothy J. Warner
with: one who creates safe spaces for Ambulatory Pharmacy Manager
Rafael Saenz, Pharm.D. University of Rochester Medical Center
other people. Administrative Pharmacy Resident Rochester, NY
Spreading recognition and praise University of Wisconsin Hospital and Strategies and Pearls for a Successful JCAHO
boosts productivity, mood, engage- Clinics Survey
Madison, WI Patricia C. Kienle, M.P.A., FASHP
ment, retention, loyalty, satisfaction, Investing in the Future: Building Leaders in Operations Director for Accreditation and
and safety. Successful leaders take an Health-System Pharmacy Medication Safety
interest in individuals’ talents, goals, Harold N. Godwin, M.S., FASHP Cardinal Health Pharmacy Management
Professor and Chair, Department of Laflin, PA
and families, and the employees val- Pharmacy Practice
ue the feeling of being known. School of Pharmacy Janet Silvester, M.B.A., FASHP
Leaders need realistic optimism: University of Kansas Director of Pharmacy Services
Kansas City, KS Martha Jefferson Hospital
seeing the world as it is but working Charlottesville, VA
positively toward a desired outcome. Mike D. Sanborn, M.S.
The key to resilience in the face of Director of Pharmacy Services Peter M. Pascale, M.S., FASHP
Baylor Healthcare System Director of Pharmacy
stress is not eliminating all day-to- Dallas, TX Erie County Medical Center
day hassles but making sure there are Improving Medication Safety through Bar Buffalo, NY
positive forces to counteract the neg- Coding
Agatha L. Nolen, M.S., D.Ph., FASHP Michael J. Sovie, Pharm.D., M.B.A.
atives. Leaders need to be spreaders Director of Pharmacy Director of Pharmacy
of positivity, and they can do this Centennial Medical Center Cardinal Health/St. Lucie Medical Center
only if they guard against burnout in Nashville, TN St. Lucie, FL
Leading through Uncontrollable Times
their own lives. Alicia B. Perry, Pharm.D. Wayne M. Sotile
Assistant Vice President, Patient Safety Moderator
Hospital Corporation of America Scott M. Mark
Corporate Quality Department Chair, ASHP Section of Pharmacy Practice
Nashville, TN Managers

1310 Am J Health-Syst Pharm—Vol 62 Jun 15, 2005