Interventions to reduce waste and improve billing compliance with medications in single-dose vials.

PURPOSE: The purpose of this process improvement project was to implement features in the electronic health record to help reduce inappropriate drug waste and Medicare billing noncompliance for injectable drugs in single-dose vials in outpatient settings. METHODS: The pharmacy department mapped processes from order entry to dose administration and claims processing. They used the process map to identify gaps that could lead to inappropriate drug waste. The organization then chose 3 drugs they believed to be at high risk of excess waste and possible billing noncompliance after cross-referencing drug cost, volume of use, and previous Medicare audits in outpatient settings. They tested a grouper and dose rounding on these drugs and compared 3 months of claims before and after implementation to assess the impact on waste and billing compliance. RESULTS: This study evaluated 826 claims before implementation and 1,075 claims after implementation. A total of 455 of 826 (55.1%) preimplementation claims included drug waste compared to 224 of 1,075 (20.8%) postimplementation claims. Twenty-three claims before implementation included an amount of waste exceeding the smallest vial size, putting the institution at risk of billing noncompliance. No claims had excess waste in the postimplementation period. The approximate cost of total drug waste before implementation was $1,397,437, with approximately $23,730 from inappropriate carfilzomib claims. The approximate cost of waste after implementation was $569,041. This equated to a reduction in drug waste of approximately $828,396 for bevacizumab-bvzr, carfilzomib, and ipilimumab. CONCLUSION: Using a grouper and implementing dose rounding, the institution reduced drug waste, saved money, and reduced the incidence of claims noncompliant with Medicare Part B billing requirements.

Implementation of implicit bias awareness and action training in a pharmacy residency program.

PURPOSE: To implement an implicit bias awareness and action seminar program for the University of Utah Health pharmacy residency program and measure knowledge, awareness, and comfort around race-related topics. SUMMARY: An implicit bias awareness training program was implemented with a pre- and post-training survey to measure knowledge, comfort, and confidence around understanding and addressing biases. Fifty-one residents and preceptors participated in the implicit bias training, and 47 (92.2%) consented to take the survey. Twenty pharmacy residents and 27 preceptors attended at least 1 of the 4 training modules and completed the pre- and/or post-training survey. Eighteen of 20 residents (90.0%) and 19 of 27 (70.4%) preceptors completed the pretraining survey (37 total), while 11 of 20 residents (55.0%) and 10 of 27 (37.0%) preceptors completed the post-training survey (21 total). On the post-training survey, more correct answers were obtained for knowledge-based questions and a higher number of responses of strongly agree or agree was observed when assessing participants' comfort and confidence in addressing personal biases, bringing marginalized people into a conversation, addressing biased situations, and intervening when bias is observed. CONCLUSION: After training, higher scores were attained on the survey for overall comfort and confidence in addressing personal biases and identifying and acting on witnessed biases.

Burnout, professional fulfillment, sleep impairment, and self-compassion within an academic medical center pharmacy department.

PURPOSE: To examine the prevalence of burnout, professional fulfillment, sleep impairment, and self-compassion within an academic medical center pharmacy department across varying job titles and practice settings. METHODS: In fall 2019, pharmacy staff completed a REDCap-based survey that consisted of a validated instrument relating to burnout, professional fulfilment, sleep-related impairment, and self-compassion. Burnout was measured by both single-item and extended 10-item questions on the survey. Survey outcomes from each domain were compared between pharmacists and pharmacy technicians/interns, as well as among practice settings (inpatient, ambulatory care, and infrastructure). RESULTS: A total of 593 surveys were completed by pharmacy personnel, representing a preliminary response rate of 71.8% (593/826). A total of 505 survey responses were analyzed (235 [46.5%] for pharmacists and 270 [53.5%] for pharmacy technicians/interns). Inpatient pharmacists reported the highest level of burnout (50.7%), followed by ambulatory care pharmacists (29.3%) and those working in infrastructure (24.3%). Pharmacy technicians working in infrastructure reported the highest level of burnout (36.4%), followed by inpatient (30.8%) and ambulatory care (28.3%) pharmacy technicians. There was no association between job type or location and burnout according to both single-item and 10-item burnout measures. A higher rate of burnout, sleep impairment, and decreased self-compassion and a lower rate of professional fulfillment were observed for inpatient pharmacists compared to pharmacists in ambulatory care or infrastructure. Except for higher rates of reported professional fulfillment, a similar trend was observed for pharmacy technicians. CONCLUSION: Burnout was reported across the pharmacy team regardless of practice site.

Adjunct Digital Interventions Improve Opioid-Based Pain Management: Impact of Virtual Reality and Mobile Applications on Patient-Centered Pharmacy Care.

Digital therapeutics (DTx, mobile medical apps, software as a medical device) are rapidly emerging as clinically effective treatments for diverse chronic diseases. For example, the Food and Drug Administration (FDA) has recently authorized a prescription virtual reality (VR) app for treatment of moderate to severe low back pain. The FDA has also approved an adjunct digital therapy in conjunction with buprenorphine for opioid use disorder, further illustrating opportunities to integrate digital therapeutics with pharmacotherapies. There are ongoing needs to disseminate knowledge about advances in digital interventions among health care professionals, policymakers, and the public at large. This mini-review summarizes accumulating clinical evidence of digital interventions delivered via virtual reality and mobile apps to improve opioid-based analgesia. We identified relevant randomized controlled trials (RCTs) using Embase and PubMed databases which reported pain scores with a validated pain scale (e.g., visual analog scales, graphic rating scale, numeric rating scale) and use of a digital intervention in conjunction with opiates. Among identified RCTs, the majority of studies reported improved pain scores in the digital intervention group, as compared to "treatment as usual" group. Our work suggests that VR and mobile apps can be used as adjunct digital therapies for pain management. We discuss these findings in the context of how digital health technologies can transform patient-centered pharmacy care.

Reduction of phone interruptions post implementation of a central call center in community pharmacies of an academic health system.

PURPOSE: A pharmacy services call center (PSCC) was implemented to centralize pharmacy phone calls and reduce interruptions of dispensing activities in 7 community pharmacies of an academic health center. An evaluation was conducted to define, quantify, and compare the numbers and types of phone interruptions before and 3 months after PSCC implementation. METHODS: Through structured, direct observation of pharmacy staff, the numbers and types of "breaks in task" (BIT) due to phone interruptions and other distractions were identified. A standardized data collection tool formatted on tablet computers was used by trained observers to document BIT for 3-hour time blocks on 5 consecutive business days (2 days of pharmacist observation and 3 days of technician observation, for a total of 10 observation days per pharmacy). RESULTS: Over 5,000 prescriptions were processed during 414 hours of observation (13.3 prescriptions per observation hour). Overall, BIT due to phone interruptions totaled 2.2 BIT per observation hour, with those interruptions reduced by 46.4% overall after PSCC implementation (by 30.0% in 4 small pharmacies and by 57.5% in 3 large pharmacies). Technicians were more likely than pharmacists to be interrupted by phone vs nonphone BIT (eg, distraction by another technician, pharmacist, or patient). Comparison of phone vs nonphone BIT suggested an overall 46.0% reduction in phone BIT in all pharmacies (reductions of 42.4% and 45.0% in large and small pharmacies, respectively). CONCLUSION: PSCC implementation noticeably decreased the amount of phone interruptions and distractions for employees.

Assessment of perceived workload in academic health center community pharmacies before and after implementation of a central call center.

PURPOSE: Results of a study to determine whether reducing pharmacy phone call workload through implementation of a pharmacy services call center (PSCC) led to decreased employee workload, improved efficiency, and increased pharmacist availability for patient care are reported. METHODS: A pre-post study was conducted using the NASA Task Load Index (NASA-TLX) instrument. Pharmacists, pharmacy technicians at 7 academic health center community pharmacies, and PSCC staff provided NASA-TLX data over 5 days during 3 data collection periods before and after PSCC implementation. Perceived workload was measured as an overall workload score (OWS) and mean scores for 6 NASA-TLX workload dimensions (mental demand, physical demand, temporal demand, performance, effort, and frustration). RESULTS: Relative to pre-PSCC values, mean postimplementation OWS scores significantly decreased in all 7 pharmacies (from 33.3 to 29.1 overall, p < 0.001) but especially in small pharmacies (from 31.7 to 27.6, p < 0.001). Scores for the physical demand and frustration dimensions were low in both the PSCC and in the 7 pharmacies, while scores for the performance dimension remained high (range, 6.8-8.3). In general, scores for all other measured NASA-TLX dimensions decreased after PSCC implementation, more so at smaller pharmacies. The PSCC staff mean OWS score increased over time (from 26.8 to 28.6, p < 0.0001) but remained near the overall pharmacy average of 29.1. CONCLUSION: Use of the NASA TLX allowed for a direct subjective measurement of workload as perceived by pharmacy and PSCC employees before and after PSCC implementation. Long-term effects of the PSCC on workload should be assessed.

Implementation of a centralized mail-order pharmacy service.

PURPOSE: The development and implementation of centralized mail-order pharmacy services in an academic healthcare system are described. SUMMARY: The use of mail-order pharmacy services continues to increase, as mail-order services offer patient benefits such as reduced copayments and improved clinical outcomes. Prior to undertaking an initiative to improve its mail-order pharmacy services, the University of Utah Health system's pharmacy department offered decentralized mail-order pharmacy services at all of its retail pharmacies, but there was no standardized process for processing mail-order prescriptions or providing phone support to mail-order patients. Centralized mail-order pharmacy services were developed and implemented by creating (1) a standard process for mail-order pharmacy services, (2) a centralized mail-order prescription filling center, and (3) a call center to support mail-order pharmacy services. Implementation of centralized mail-order pharmacy services resulted in an almost 50% reduction in time spent by pharmacy team members on mail-order prescription filling and packaging tasks. Use of a central call center resulted in a decreased call abandonment rate and contributed to a decreased pharmacy workload resulting from an overall reduction in call volume due to an increased rate of first-call issue resolution. CONCLUSION: Establishment of a centralized mail-order pharmacy service along with operational and infrastructure improvements resulted in improved quality and regulatory compliance and enhanced labor efficiency and patient communication.

Effect of a central call center on employee perceptions of safety culture within community pharmacies in an academic health system.

PURPOSE: This study evaluated employee perceptions of safety culture in 9 health-system-owned community pharmacies using a safety culture survey before and after implementation of a Pharmacy Services Call Center (PSCC) designed to reduce distractions through reduction of phone volume related to refills and prescription readiness. METHODS: The Agency for Healthcare Research and Quality (AHRQ) Community Pharmacy Survey on Patient Safety Culture (CPSPSC) was used to collect employee safety culture perceptions pre-post PSCC implementation. A percent positive score (PPS) was calculated for each of 11 CPSPSC composite questions and for 1 overall rating of patient safety question based on AHRQ-suggested analytic procedures. Pre-post PSCC implementation, PPSs were compared using a chi-square test. RESULTS: Overall, the lowest composite PPS (Staffing, Work Pressure, and Pace) and the highest composite PPS (Patient Counseling) ranked the same in both survey periods. Of the nine PSCC pharmacies, statistically significant (p < 0.05) PPS improvements occurred in 4 composites including Teamwork (11.9%), Communication About Mistakes (18%), Staff Training and Skills (20.6%), and Staffing, Work Pressure, and Pace (11.8%). PSCC pharmacies also reported a 9.3% (NS) improvement in overall rating of pharmacy patient safety post PSCC implementation. Separate analysis of pharmacist responses was consistent with pharmacy level results, but technician results differed slightly in overall rating of safety perceptions. CONCLUSION: Presence of the PSCC appeared to increase pharmacy employees' perceptions of safety culture in the community pharmacies, an integral part of overall patient safety.

Use of multiple methods to measure impact of a centralized call center on academic health system community pharmacies.

PURPOSE: The process and methods used in an impact assessment of a centralized pharmacy call center on community pharmacy employee patient safety climate perceptions, telephone distractions/interruptions, and prescription filling efficiency are described. SUMMARY: A broad-based team designed a multi-faceted, pre-post call center implementation analysis that included multiple change assessment measures. First, yearly administration of the Agency for Healthcare Research and Quality Community Pharmacy Survey on Patient Safety Culture was used to assess patient safety climate based on employee perceptions of a safe working environment and potential for errors due to interruptions and distractions. Evaluative measures of staff workload that assessed telephone interference with prescription filling activities pre and 3 months post implementation included (1) the NASA Task Load Index, (2) multi-tasking observations through shadowing of pharmacists and technicians to count number of interruptions/distractions per prescription "touched," and (3) self-reported work sampling to assess proportional time estimates of clinical, professional, and technical activities. Finally, pharmacy efficiency and prescription filling capacity were assessed using operational measures (prescriptions filled, patients served, phone call volume changes, prescription rework counting). Data analysis included summary statistics, Student's t-test, and chi-square analysis, as appropriate, in addition to assessing convergence and agreement among measures. Every evaluative method showed a positive outcome from call center implementation, although individual pharmacies may have accrued greater benefit from call reduction than others. CONCLUSION: Multiple analysis methods can be used to evaluate the impact of workflow changes.

Development and implementation of a centralized comprehensive refill authorization program in an academic health system.

PURPOSE: The development and implementation of a centralized, comprehensive, refill authorization (CCRA) program within an academic health system are described. SUMMARY: In order to improve continuity of care for our medically complicated patients, ambulatory pharmacy services developed and implemented a highly coordinated CCRA program for multiple community clinics within the system. To implement the CCRA program, we centralized the refill-request intake process to the Pharmacy Ambulatory Clinical Care Center (PAC3). PAC3 technicians were incorporated into the refill authorization process, and the collaborative practice agreement was updated to standardize the pharmacist refill approval process at the PAC3. We successfully standardized and centralized the medication refill process from 10 community clinics with 95 family practice and internal medicine providers and 26 medical residents. We handled an average of 12,000 refill requests each month, and pharmacists documented any interventions performed with each refill request. The cost savings associated with the CCRA program were attributed to the increased efficiency of the staff reviewing refill requests. The CCRA program increased the refill approval up to 10% compared with the previous decentralized refill authorization model. With the increased approval rate, the CCRA program saved 510 hours of our providers' time annually, which created time for an additional 1,530 clinic visits. We demonstrated a faster average turnaround time for refill authorization, from an average of 72 hours before implementation to about 1 business day. CONCLUSION: Implementation of an integrated refill authorization service standardized the method by which patients' refill requests were addressed, increased refill efficiency, and improved refill authorization turnaround time.

Potential Association between Drug Shortages and High-Cost Medications.

Shortages and sudden price increases of certain drugs may both occur emergently, with little to no warning, and they can have a dramatic impact on patient care. Little data are available linking drug shortages and price increases. Many of the same characteristics that may make medications susceptible to shortages can also place them at risk for sudden price increases. These characteristics include unapproved drugs, off-patent sole-source medications, and infrequently used medications. We reviewed drug shortage data from the University of Utah Drug Information Service to demonstrate how frequently these characteristics occurred and resulted in higher drug prices. Clinicians can use drug shortage management principles to mitigate the impact of sudden price increases for patients and health care organizations.

Visual compatibility of i.v. medications routinely used in bone marrow transplant recipients.

PURPOSE: The visual compatibility of i.v. medications routinely used in bone marrow transplant recipients was studied. METHODS: A total of 17 drug combinations were tested using simulated Y-site administration. Medications were prepared to the standard concentrations used at University of Utah Health Care and infused at the appropriate rate. For each combination, the two drugs had 99 cm of shared tubing. At the end of the shared tubing was a 0.8-microm filter disk. All of the drug combinations were tested in triplicate. After the infusion was complete, each filter was bubble-point tested to ensure filter integrity and to remove residual solution. The tubing and dried filter were examined by eye as well as a magnification microscope. Drug combinations were considered incompatible if a precipitate or color change was visible to the naked eye during filtration or if the number of particles observed under the microscope exceeded 12 particles of > or =10 microm in diameter per milliliter of solution or if 2 or more particles of > or =25 microm in diameter per milliliter of solution were observed, per guidelines established by the United States Pharmacopeia for large-volume injections. RESULTS: Of the 17 drug combinations tested, 5 combinations were observed to be visually incompatible. All of the incompatible combinations included acyclovir as the primary infusion. Acyclovir was incompatible with cyclosporine, diphenhydramine, gentamicin, granisetron, and metoclopramide. CONCLUSION: Of the 17 drug combinations tested, 5 combinations were observed to be visually incompatible during simulated Y-site injection. The combinations found to be visually incompatible included acyclovir with cyclosporine, diphenhydramine, gentamicin, granisetron, or metoclopramide.