Implementing a Decentralized Model

Report
Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
Implementing a
Decentralized Model
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
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!
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.
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!
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
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
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
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
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
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
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
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
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
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.
Measuring the Results
• Retention of Pharmacists (varying
reasons for leaving, but nonetheless,
concerning)
– Year Prior - 21% turnover
– Implementation Year - 5% turnover
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
Clinical Data
Pharmacist Interventions
Before and After Decentralization
Interventions
800
600
Interventions
400
200
0
n
Ja
M
ar
M
ay
l
Ju
Month
p
Se
v
No
n
Ja
nu
a
gu
s
ly
t
pt
em
be
r
O
ct
ob
N
ov er
em
b
D
ec er
Ja em
b
nu
ar er
y
20
08
Se
Au
ne
Ju
Ju
ril
ay
M
Ap
Fe ry
br
ua
ry
M
ar
ch
Ja
IV to PO Interventions
IV to PO Summary
Interventions
140
120
100
80
60
40
20
0
Month
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
Future:
• Nursing inservices
• Increase involvement in medication
reconciliation/discharge counseling
• Student mentoring/precepting in focused
areas (Cardiology)
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

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