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Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose An increasing focus on driving margin has pushed health-system pharmacy departments to find new ways of generating new or protecting existing revenue. At UNC Health, a dedicated pharmacy revenue integrity (PRI) team has been operating since 2017. This team has been able to significantly reduce revenue loss from denials, increase billing compliance, and improve revenue capture. This article provides a framework for establishing a PRI program and reports results generated from it. Summary The activities of a PRI program can be grouped into 3 main pillars: minimizing revenue loss, optimizing revenue capture, and ensuring billing compliance. Minimizing revenue loss is accomplished primarily through management of pharmacy charge denials and can be an ideal first step in establishing a PRI program due to the tangible value generated. Optimizing revenue capture involves a combination of clinical expertise and understanding of billing operations to ensure medications are being billed and reimbursed appropriately. Finally, ensuring billing compliance, including ownership of the pharmacy charge description master and maintenance of electronic health record medication lists, is vital in preventing charge and reimbursement errors. Conclusion Successfully bringing traditional revenue cycle functions into the department of pharmacy can be a daunting task but provides significant opportunities to create value for a health system. Key factors to the success of a PRI program include robust data access, hiring individuals with financial and pharmacy expertise into PRI positions, strong relationships with the existing revenue cycle teams, and a progressive model that allows for incremental expansion of services.

A key part to assimilating into an organization in a leadership role is managing transitions. Health-System Pharmacy Administration and Leadership (HSPAL) Residency Programs focus on laying the foundation for continued growth in management and leadership skills. This article focuses on keys for transitioning from HSPAL Pharmacy Resident to Pharmacy Leader. Managing transitions is and will continue to be an important topic for all leaders. As HSPAL Residents transition to new pharmacy leaders, understanding pharmacy practice building relationships, maintaining them, and having a thoughtful strategy through this transition will allow for a more complete understanding of the organization to navigate complexities, develop people, and complete projects and initiatives. While this article is specific to HSPAL residents, these concepts can apply to the transition to pharmacy leaders.

Purpose The 2020 Safe to Touch Consensus Conference on Hazardous Drug Surface Contamination was convened in order to gather subject matter experts in the field of hazardous drug (HD) handling to develop consensus statements regarding surface contamination monitoring for adoption by stakeholders in the drug supply chain, policy, and healthcare arenas. Summary The Safe to Touch conference convened virtually on September 22, 24, and 26, 2020. An expert panel of healthcare providers with experience in HD handling, monitoring, and research; pharmacy and nursing operations; and medication safety led the conference. An experienced audience of approximately 25 reaction panel members provided feedback to the panel via a preconference survey, during the conference, and at a postconference virtual town hall. Additionally, expert speakers presented on a range of issues, including the impact of HD surface contamination on health, current regulations and standards, surface contamination monitoring technologies, and variables impacting surface contamination testing. Conclusion At the end of the conference, the expert panel developed 11 consensus statements and corresponding recommendations that should be widely disseminated in order to educate individuals regarding the impact of HD surface contamination and increase the scope of HD surface contamination monitoring. Institutions involved in the handling of HDs should set short- and long-term goals for implementation of applicable consensus statements.

Purpose: The purpose of this study is to assess the impact of a clinic embedded Medication Assistance Program (MAP) specialist on the prescription benefit prior authorization (PA) process and provider satisfaction in an adult pulmonary clinic. Methods: In this mixed methods study, a retrospective cohort analysis was done to determine the turnaround time for the PA process from initial referral to approval or final denial in an adult pulmonary clinic. Additionally, a pre- and post-implementation survey to providers was conducted to assess provider satisfaction and perceptions around the prescription benefit PA process. The first study aim assessed PA efficiency by summarizing PA approval rate and PA turnaround time using descriptive statistics. Any prescriptions written by a clinic provider requiring a PA during the timeframe of June 2018 through August 2018 were included. The second study aim assessed change in provider satisfaction, analyzed via the Mann-Whitney U test. Results: The MAP specialist completed 110 PAs over 3 months for 110 unique patients. Median turnaround time was 3 hours, with 76% of PAs approved in less than 24 hours. Initial approval rate was 82.7%, and overall approval rate following the appeals process was 87.3%. A significant difference between the pre- and post-survey responses were identified in 2 of the 17 questions. Conclusion: Implementation of a clinic embedded MAP specialist to complete PAs demonstrated an efficient process while also improving provider satisfaction.

Purpose A common denial trend that occurs with “outpatient medical benefit drugs” (ie, medications covered by a medical benefit plan and administered in an outpatient visit) is payers not requiring or permitting prior authorization (PA) proactively, yet denying the drug after administration for medical necessity. In this situation, a preemptive strategy of complying with payer-mandated requirements is critical for revenue protection. To address this need, our institution incorporated a medical necessity review into its existing closed-loop, pharmacy-managed precertification and denials management program. Summary Referrals for targeted payers and high-cost medical benefit drugs not eligible for PA and deemed high risk for denial were incorporated into the review. Payer medical policies were evaluated and clinical documentation assessed to confirm alignment. This descriptive report outlines the medical necessity workflow as a component of the larger precertification process, details the decision-making process when performing the review, and delineates the roles and responsibilities for involved team members. A total of 526 drug orders were evaluated from September 2018 to August 2019, with 146 interventions completed. Of the 761 individual claims affected by proactive medical necessity review, 99.2% resulted in payment and less than 1% resulted in revenue loss, safeguarding more than $5.3 million in annual institutional drug reimbursement. At the time of analysis, there were only 3 cases of revenue loss. Conclusion Our institution’s pharmacy-managed medical necessity review program for high-cost outpatient drugs safeguards reimbursement for therapies not eligible for payer PA. It is a revenue cycle best practice that can be replicated at other institutions.

In an era of soaring drug prices, payers have developed complex strategies to manage costs and ensure clinically appropriate prescribing in the outpatient environment.1–3 Some of the most frequentl...

Purpose To evaluate the impact of remote sterile product pharmacist checks when used with a gravimetric-based technology-assisted workflow (TAWF) system on product checking accuracy, pharmacist review time, workload sharing, cost savings, and staff perceptions. Methods A double-arm, prospective study was conducted at 4 pharmacy locations for a 90-day period. Each compounded sterile product (CSP) checked by a remote pharmacist was also checked by a local pharmacist at the site of CSP preparation. An anonymous, online survey was emailed to staff before and after implementation to evaluate perceptions of the accuracy, timeliness, safety, potential impact, and value of the remote process. Results There was no statistically significant difference in the numbers of errors detected through the remote process and through the current, nonremote process (P = 0.177). The median pharmacist review time in the local process was significantly lower (P < 0.001). Remote pharmacists in the study workflow verified 30.4% of the total number of CSPs verified in the 90-day period. Annualized cost savings were calculated to be $23,770.08. Percent agreement increased from the preimplementation to the postimplementation period for survey questions about the safety of the remote process, opportunity for workload sharing, and optimization of current workflow. Percent agreement decreased for questions about the accuracy, timeliness, and value of the remote process and its impact on job security. Conclusion The study demonstrated that with use of a gravimetric-based TAWF system, there was no difference in the accuracy and safety of sterile product pharmacist checks performed remotely and those performed at the product preparation site. In addition, the remote process allows for opportunities for workload sharing and cost savings.

Purpose To determine the density variation between (1) the measured density and manually calculated density, (2) density variation of different lots, and (3) density variation of different drug manufacturers in order to support institutions using gravimetric compounding methods. Summary Seventeen sterile injectable ingredient (drug) vials frequently used to make compounded sterile products (CSPs) were identified based on the ability to ensure that for each drug there were vials produced by 2 different manufacturers and 2 lots produced by the same manufacturer. Each drug’s density was measured using a density meter and by manual calculation using the institution’s density formula. Density differences were compared between the 2 different methods. Overall, the average drug density difference between the measured versus calculated density was determined to be 0.022. Further analysis revealed the average difference between the different lot numbers of the same manufacturers was 0.005 for the nonhazardous drugs and 0.0001 for the hazardous drugs. The average difference between the different manufacturers of the same drug was determined to be 0.008 for the nonhazardous drugs and 0.001 for hazardous drugs. Conclusion No clinically meaningful difference exists when manually calculating a drug’s density compared to measuring a drug’s density using a density meter. In addition, there does not appear to be a sizeable density variation between the same drugs in separate lots or produced by different manufacturers.

Background: Microbial contamination of compounded medications is a serious concern within hospital pharmacies as it can lead to severe patient injury. The United States Pharmacopeia mandates that pharmacy personnel responsible for preparing compounded sterile preparations must annually demonstrate competency in aseptic technique by performing a media-fill challenge test. Objective: The purpose of this study is to evaluate the sensitivity of a commonly used media-fill test through proper and improper compounding techniques. Methods: Two aseptically trained pharmacy technicians performed media-fill challenge testing by carrying out 5 separate manipulations 5 times each for a total of 25 trials. Sterile vials, syringes, and intravenous bags were prepared. The first manipulation followed best-practice aseptic technique and sterile compounding procedures. Each of the following 4 manipulations removed one aspect of best-practice aseptic technique. The prepared products were incubated at 20°C to 25°C. A positive result for microbial contamination is indicated by visible turbidity within the vials, syringes, and intravenous bags at the following check points: 24 hours, 72 hours, 7 days, 14 days, 21 days, and >30 days. Results: Twenty-five trials, each containing 10 distinct admixtures, resulted in a total of 250 compounded preparations. No single preparation showed signs of turbidity, sedimentation, or visible microbial growth at any of the 6 checkpoints yielding a 0% contamination rate. However, the positive controls inoculated with bacteria did have positive microbial growth results. Conclusion: A more sensitive test needs to be developed to provide assurances that all poor aseptic practices are detected in compounding personnel.

Background Incident reporting systems allow for frontline employees to report errors and are a critical component of healthcare patient safety programs. Although incident reporting systems cannot quantify total errors, organizations can utilize incident reporting systems to help identify risks and trends to act upon. The objective of this article is to utilize incident reporting systems to evaluate trends in medication error reporting before and after implementation of a new electronic health record system. Methods A five-month pre- and post-analysis was completed in a cancer hospital following electronic health record conversion by reviewing medication errors reported via the institution’s voluntary incident reporting systems. Error reports included medication error category, date error was reported/occurred, patient location at time of error, harm severity score, medication(s) involved, medication use system node error originated/discovered in, medication source, narrative summary, and contributing factors. Data were analyzed using descriptive statistics within Office Excel. Results Oncology medication error reports submitted pre- and post-electronic health record were 68 vs. 57, respectively. During the pre- and post-electronic health record conversion, a majority of errors had a harm severity index of 0 or 1; 12 (18%) in pre-electronic health record and 3 (5%) in post-electronic health record were level 2, and one (1%) in pre-electronic health record vs. 0 in post-electronic health record were level 3. Reported medication errors originated most commonly during the prescribing, administration, and preparation/dispensing phase and were primarily identified in the administration phase of the medication use process. The most frequently reported error category was ‘wrong dose’ followed by ‘other’ and ‘overdose’ in the pre-electronic health record phase and ‘missing dose/delayed delivery’ and ‘order incorrect’ in the post-electronic health record phase. The most frequently reported medications included methotrexate, chemotherapy (unspecified), and cisplatin. Conclusion Analyzing data from incident reporting system reports allowed our institution to understand different trends of reporting in the cancer hospital following electronic health record adoption. Utilization of incident reporting systems must be combined with proactive risk identification approaches to enable systems-focused improvements to improve patient safety.

Purpose The impact of a gravimetric-based technology-assisted workflow (TAWF) system on the nonhazardous compounded sterile product (CSP) error capture rate, production times, and pharmacy staff perceptions of compounding methods was evaluated. Methods For 2 weeks prior to TAWF implementation, staff used a punch clock to document production times with a volumetric method. Preimplementation error data were captured in a previous study; TAWF software captured error and time data in the postimplementation period. An online staff survey was administered before and 90 days after TAWF implementation to evaluate perceptions of the 2 methods. Results The error capture rates were 0.47% in the preimplementation period and 41.48% in the postimplementation period. The median time to prepare CSPs was significantly shorter in the preimplementation period versus the postimplementation period (p < 0.0001). The median time to check CSPs was significantly shorter at both 90 days (p < 0.0001) and 180 days (p = 0.0006) after TAWF implementation. When asked if the current method was the safest and the most accurate method for preparation, staff members’ perceptions improved from neutrality to agreement when the TAWF was implemented. Staff members were in agreement that the volumetric method was faster than the gravimetric TAWF method but were neutral as to whether the latter was the preferred compounding method. Conclusion The study results indicated that gravimetric-based TAWF preparation of nonhazardous CSPs is slower than manual volumetric preparation but can improve the error capture rate. Staff perceived the gravimetric TAWF method to be the safest and most accurate for producing CSPs.

Purpose Nurse practitioners, physician assistants, and pharmacists are advanced practice providers who are highly trained and qualified healthcare professionals that can help support traditional demands on oncologists' increased time in direct patient care. The purpose of this study was to detail and assess the creation of a privileging process for this group of medical professionals within an academic medical center. Obtaining the designation of limited oncology practice provider (LOPP) gives the right to modify chemotherapy orders and to order supportive care medications. Methods An interdisciplinary team developed a comprehensive training process inclusive of required educational domains, knowledge goals, and educational activities to become an LOPP. In 2018, five years after the implementation of the privileging process, a survey was distributed to assess perceptions of the training process and integration of LOPPs within oncology practice. Results Most oncologists noted that working with LOPPs is beneficial to oncology practice (94%) and that they make modifying chemotherapy orders more efficient (87%). Greater than 82% of LOPPs also reported that their privileges streamline the chemotherapy process and make them feel valuable. Conclusion The creation of the LOPP designation is an effective way to integrate nurse practitioners, physician assistants, and pharmacists within oncology practice. The inclusion of a focused privileging process ensures the safety of cancer care provided and has created a streamlined process for chemotherapy modifications and supportive care.

Purpose This case study describes a multidisciplinary initiative to promote the safe use, preparation, and administration of bacillus Calmette-Guerin (BCG) in patients with bladder cancer that is in compliance with United States Pharmacopeia chapter 800. Summary After an evaluation of a hospital's medication-use process for the preparation and administration of BCG identified inconsistencies with guideline-based procedures for the safe handling and manipulation of hazardous drug products, a revised medication-use process promoting the inclusion of pharmacy services was developed by pharmacy and urology clinic leaders. Implementation of the enhanced medication-use process included (1) the shift of BCG vaccine preparation from urology clinic nurses to a pharmacy equipped with the appropriate engineering controls for the safe preparation of hazardous product, (2) greater involvement by pharmacists in BCG order justification and verification, and (3) a process that ensured just-in-time preparation and delivery of medication for enhanced patient satisfaction. After initial process changes resulted in increased turnaround time from preparation to administration, a study on time to preparation, delivery, and administration was conducted and resulted in complete reduction of turnaround times and increased patient satisfaction. Conclusion Through a multidisciplinary initiative involving pharmacists, physicians, nurses, and leadership, a new process to promote the safe preparation and administration of the tuberculosis vaccine Mycobacterium bovis BCG was developed and implemented. The results of a post-implementation time study indicated that a standardized approach to scheduling, preparing, and administering BCG was effective in managing the operations of BCG through having high clinic and patient satisfaction.

In 2009 the University of North Carolina (UNC) Medical Center opened the North Carolina Cancer Hospital to serve as the premier location for oncology patients in the state. For the Department of Ph...

The objective of this study was to describe the response by state boards of pharmacy pertaining to personal protective equipment shortages during the early phase of the COVID-19 pandemic. All webpages of state boards of pharmacy were independently reviewed for written guidance pertaining to personal protective equipment conservation strategies in sterile compounding and deviations from United States Pharmacopeia General Chapter797standards; each guidance was then reviewed for referenced sources. Of 52 state pharmacy regulatory bodies, 38 (73.08%) provided guidance to modifying personal protective equipment use during sterile compounding activities to mitigate supply shortages. The references for each guidance varied, however, most referenced CriticalPoint, LLC or the United States Pharmacopeia. A few of the guidance documents from boards also permitted other deviations from United States Pharmacopeia Chapter797standards. Early in the pandemic, pharmacists within sterile compounding practices had to conserve personal protective equipment while mitigating contamination risk. Pharmacists looked to state boards of pharmacy for guidance. This report shows a high level of state response to the personal protective equipment shortage induced by the pandemic.

Purpose Required competency areas, goals, and objectives for both postgraduate year 1 (PGY1) pharmacy residencies and postgraduate year 2 (PGY2) health-system pharmacy administration and leadership (HSPAL) residencies indicate the importance of research in the residency program by specifying it as a required part of the training process. Research is critical in the field of health-system pharmacy administration, which is built upon the principles of evaluation and assessment, ensuring that all activities implemented in an organization are evaluated through data collection and assessment to determine their impact. Additionally, the research structure provides residents the opportunity to share research broadly, and it also provides the platform for other institutions to implement successful ideas of interest to them. Summary This article describes the impact of having a structured, publication-focused research program in an HSPAL residency. The research process has provided follow-up projects (n = 7) and grant participation (n = 6). Additionally, the process has yielded a 66% publication rate, with 21 of 32 thesis substitutes published in various journals. The department of pharmacy at the residency site has noticed that the continued refinement, scoping, and robust methodologies of projects have been essential to their impact in the literature and in dissemination of the accumulated body of knowledge. Conclusion A structured residency research program has provided direction to HSPAL residents and ensured successful scoping and completion of their research. Intentionality in this aspect has provided HSPAL residents with opportunities for publications, grants, and strong research experiences. Overall, the department of pharmacy has been positively impacted through implementation of services that were evaluated through a structured HSPAL pharmacy residency research program.

Purpose UNC Medical Center converted to an electronic health record (EHR) in 2014. This conversion allowed for the transition of paper chemotherapy orders to be managed electronically. This article describes the process for converting inpatient paper chemotherapy orders into the new EHR in a safe and effective manner. Summary A collaborative interdisciplinary approach to the EHR transition enabled our organization to move from using paper chemotherapy orders to fully electronic chemotherapy treatment plans in both ambulatory and acute care areas. Active chemotherapy orders for acute care inpatients were reviewed and transcribed by two oncology pharmacists in the cancer hospital prior to being signed by an attending physician. The newly input orders were independently verified by two pharmacists in the cancer hospital inpatient pharmacy. Nurse review of the signed and verified treatment plans, along with reconciliation of the medication administration record ensured a safe transition to the new EHR workflow. Providers benefit from the ability to review treatment plans remotely, track changes, and include supportive medications in one consolidated location. The coordinated team effort allowed for a smooth transition with minimal interruptions to patient care. Conclusion The pharmacist-led, multidisciplinary conversion to electronic chemotherapy orders was safe, accurate, and occurred ahead of schedule for the EHR go-live. Advance communication and planning around scheduled inpatient admissions helped to minimize the impact of the transition from paper to electronic treatment plans. Both pharmacist and physician engagement were necessary to ensure a smooth transition for active inpatient treatment plans.

PURPOSE The impact of a gravimetric-based technology-assisted workflow (TAWF) system on hazardous compounded sterile product (CSP) production time, staff perception of safety, and job satisfaction was evaluated. METHODS For 2 weeks before implementation of a gravimetric-based TAWF, staff utilized an automated punch clock to document the time to prepare and check CSPs compounded volumetrically. Simultaneously, an anonymous, online survey was e-mailed to staff to evaluate their perceptions regarding the safety of volumetric preparation and satisfaction with their role preparing CSPs. At 30 and 90 days postimplementation of the TAWF, staff completed identical follow-up surveys to evaluate safety and satisfaction using the gravimetric-based TAWF. The TAWF software captured product preparation and check times postimplementation. Data regarding the accuracy of compounding were collected postimplementation and compared to accuracy data available in the published literature. RESULTS The median time to prepare CSPs preimplementation (n = 643) was 445 seconds versus 359 seconds (n = 728) 90 days after implementation of the gravimetric-based TAWF (p < 0.001). The median time to review and check CSPs was 45 seconds before implementation and 19 seconds 90 days after implementation (p < 0.01). Survey respondents preferred to use the TAWF to compound CSPs over volumetric preparation. There was no difference in respondents' perception of safety and accuracy of the TAWF preimplementation versus postimplementation. CONCLUSION The gravimetric-based TAWF preparation of hazardous CSPs was faster and more accurate than manual volumetric preparation and improved staff perception regarding the accuracy of the CSP preparation process.

Purpose: To address the growing use of oral anticancer therapy, an integrated, closed-loop, pharmacist-led oral chemotherapy management program was created within an academic medical center. Methods: An integrated, closed-loop, pharmacy-led oral chemotherapy management program was established. From September 2014 until June 2015, demographic information, rates of adherence, patient understanding of treatment, pharmacist interventions, patient and provider satisfaction, and molecular response rates in patients with chronic myeloid leukemia (CML) were collected. Results: After full implementation, 107 patients were enrolled in our oral chemotherapy management program from September 2014 until June 2015. All patients were educated before starting oral chemotherapy, and using pre- and postassessment tests, comprehension of oral chemotherapy treatment increased from 43% to 95%. Patient-reported adherence was 86% and 94.7% for the GI/breast and malignant hematology patient populations, respectively, and these were validated with medication possession ratio, revealing adherence rates of 85% and 93.9% for the GI/breast and malignant hematology patient populations, respectively. A total of 350 encounters with a clinical pharmacist and 318 adverse effects were reported, which led to 235 interventions. This program led to a higher major molecular response rate (83%) in our CML population compared with published clinical trials (average major molecular response rates, 40% and 60% with 1- and 2-year follow-up, respectively). Conclusion: An innovative model was developed and resulted in improved patient knowledge regarding oral chemotherapy, improved adherence rates that exceeded nationally established thresholds, and superior major molecular response outcomes for patients with CML compared with published literature. As a result, this model has produced the gold standard in managing patients receiving oral chemotherapy.

Background Competency-based education models can serve as valuable resources for providing quality continuing education and professional development in healthcare. However, competency development programs can be stifled by scarce stakeholder involvement and insufficient recognition of resource challenges. Engaging pharmacists in program development can inform program design and prioritization of needs. Objective To describe a process to assess pharmacist perceptions about competency development and to inform program design by identifying high priority topic areas based on perceived value, confidence in abilities, and frequency of use by pharmacists. Methods Pharmacists at a large academic medical center were surveyed to examine opinions regarding competency development and identify perceived departmental value, personal confidence, and frequency of use for nine competency topic areas. Responses were aggregated to create scores for each of the three criteria related to the nine topics. Priority areas were topics with the highest relative scores in perceived value and frequency of use and lowest relative scores in confidence compared to the other areas. Results Survey responses were collected from 105 pharmacists (78.9% response rate). A majority indicated that competency assessment is a shared responsibility between the organization and individual pharmacists. Therapeutic knowledge was identified as the competency requiring the most immediate attention as it was perceived to have the highest departmental value and highest frequency of use, yet participants indicated low confidence regarding the topic. Conclusions Competency development is a critical aspect of ensuring pharmacists are prepared for the rapidly evolving needs of the healthcare system. Organizations play an important role in identifying and developing pharmacist competencies aligned with institutional and individual needs. This study suggests that pharmacists and leaders at an academic medical center identified a shared responsibility for competency development. The process described here may provide a model for other medical centers with similar competency development needs.

Purpose Implementation of an integrated pharmacy supply management strategy is described. Summary In 2011, the formulary approval process and supply management for oncology medications were independent of each other at an oncology infusion center. Numerous nonformulary medications were kept on hand and reordered based on inventory levels that were established with inadequate usage information, while some formulary agents did not have on-hand inventory levels and had to be reordered on a patient-specific basis, which required paperwork and then a review by drug information staff per institutional policy. Because there was no true distinction in the ordering of formulary versus nonformulary oncology agents, the medical staff prescribed both in the same manner, leaving the pharmacy staff responsible for ensuring that enough quantities were on hand for many drugs, regardless of formulary status. Using supply chain management principles, a formal analysis of the on-hand inventory was performed. In addition, the formulary process for oncology drugs was restructured to align with how oncology drugs are managed for on-hand inventory levels. The alignment of these processes allowed the operation to have 1 supply strategy for the ambulatory oncology infusion center. As a result, inventory exhaustion rates were reduced by 70% and inventory turn rates improved by 78%. There was also significant time savings in the operational process streamlining, eliminating the rework and inefficiencies caused by an unclear process that was not fully captured in this assessment. Conclusion Alignment of the formulary review process with inventory analyses that support supply management principles reduced inventory exhaustion while improving inventory turn rates.

Background Healthcare systems and policy makers worldwide are demonstrating interest in shared decision making, which requires patient activation. Patient activation can be measured using a validated tool called the patient activation measure-10. First cycle comprehensive chemotherapy consultation services (3CS) is provided by an oncology pharmacy team member during a patient encounter at the beginning of the patient's treatment for cancer. Methods This was a single center, prospective, non-randomized, observational clinical study in patients with cancer who required a new chemotherapy plan. A baseline patient activation measure-10 survey was administered and a pharmacy team member met with the patient to complete the first cycle 3CS encounter. Within two business days of that encounter, a second patient activation measure-10 survey was administered, and thus, patients served as their own control. Results Forty-nine patients who met the inclusion criteria were enrolled, of which 36 completed the study. Mean patient activation measure-10 scores measured at baseline and two business days after the 3CS encounter were significantly different (68.5 ± SD 14.7 vs. 75.0 ± SD 14.3, p = 0.001). This difference persisted when evaluated by gender (female: 70.0 ± SD 14.8 vs. 81.6 ± SD 10.5, p = 0.001; male: 66.1 ± SD 14.8 vs. 70.8 ± SD 14.7, p = 0.022). Conclusion This study demonstrates that cancer patients had significantly increased patient activation scores after engagement in a 3CS encounter provided by an oncology pharmacy team. Further studies are needed to verify these data in a larger population, different healthcare settings, and to evaluate for patients who have solid tumor malignancies.

Purpose The outcomes of a patient-centered layered learning practice model (LLPM) in which the clinical specialist acted as the attending pharmacist and managed a pharmacy team to provide direct patient care were evaluated. Methods Two 30-day evaluations were conducted on the acute care malignant hematology and medical oncology services of the University of North Carolina Medical Center in 2011. The primary objective of this study was to design an LLPM that used a team to expand the pharmacist care services offered. The primary outcome was the frequency of pharmacy team encounters at discharge (medication reconciliation and counseling), termed the discharge capture rate . Results During the study months, 42 and 78 malignant hematology and medical oncology patients were eligible for study inclusion, respectively. The overall discharge capture rate was 51%. Sixty-one patients received discharge medication reconciliation services during patient counseling. Patients included in the malignant hematology group received a mean of 11 prescriptions at discharge, compared with 9.83 in the medical oncology group. Means of 1.26 and 2.1 medication-related problems per patient were identified in the malignant hematology and medical oncology studies, respectively, during discharge medication reconciliation. The overall mean face time spent per patient was 21.3 minutes. Conclusion Patients in malignant hematology and medical oncology services were counseled and provided discharge medication reconciliation by a pharmacy student or resident whose activities were managed and reviewed by an attending pharmacist using an LLPM, resulting in an improvement in all clinical outcomes and measures.

Background: Hospital length of stay (LOS) is an important measure to determine resource utilization and efficiency of care for inpatients. No existing objective methodology is available to determine where and how pharmacy departments can have maximal impact on reducing extended LOS. Objective: An objective methodology to guide decisions by hospital pharmacy departments on reducing extended LOS is described. Methods: University of North Carolina Medical Center’s LOS was compared to hospitals with similar inpatient bed size and case mix index. Objective methodology using pharmacy intensity weight, LOS index, and relative number of cases overall and by hospital service was developed to identify targets of impacting LOS for a pharmacy department. Results: The novel Pharmacy Opportunity Length of Stay (POLOS) formula was developed to prioritize each Medicare Severity Diagnosis Related Group (MSDRG) based on the overall impact pharmacy can have on reducing extended LOS at an individual institution. An additional novel formula, Service Specific POLOS (SSPOLOS), was created to strategically target hospital services, as opposed to MSDRGs, allowing for effective deployment of targeted pharmacy interventions to decrease extended LOS. Conclusion: POLOS and SSPOLOS are novel formulas to guide pharmacy departments in objectively prioritizing and targeting resources to reduce extended LOS. The novel formulas can be used to quantify LOS performance at the hospital and pharmacy specific levels, in addition to providing a hospital service approach to launch LOS initiatives at health care institutions. To our knowledge, this represents the first opportunity for hospital pharmacy departments to objectively target and reduce extended LOS.

Purpose: To assess the feasibility of engaging second professional year student pharmacists in the medication reconciliation process on hospital and health system pharmacy practice outcomes. Methods: Student pharmacists in their second professional year in the Doctor of Pharmacy degree program at our institution were randomly selected from volunteers to participate. Each participant completed training prior to completing three 5-hour evening shifts. Organizational metrics, student pharmacist perception regarding quality of interactions with health care professionals, and pharmacist perceptions were collected. Results: A total of 83 medication histories were performed on complex medical patients (57.0 ± 19.2 years, 51% female, 65% Caucasian, 12 ± 6 medications); of those, 93% were completed within 24 hours of hospital admission. Second professional student pharmacists completed on average 1.9 ± 0.6 medication histories per shift (range 1-3). Student pharmacists identified 0.9 medication-related problems per patient in collaboration with a pharmacist preceptor. Student pharmacists believed the quality of their interactions with health care professionals in the Student Medication and Reconciliation Team (SMART) program was good or excellent. The program has been well received by clinical pharmacists involved in its design and implementation. Conclusion: This study provides evidence that second professional year student pharmacists can assist pharmacy departments in the care of medically complex patients upon hospital admission.

This article outlines challenges and solutions to new managers onboarding within a department of pharmacy.

Background: Despite widespread recognition of the need for innovative pharmacy practice approaches, the development and implementation of value-based outcomes remains difficult to achieve. Furthermore, gaps in the literature persist because the majority of available literature is retrospective in nature and describes only the clinical impact of pharmacists’ interventions. Objective: Length of stay (LOS) is a clinical outcome metric used to represent efficiency in health care. The objective of this study was to evaluate the impact of pharmacist-driven interventions on LOS in the acute care setting. Methods: A separate samples pretest-posttest design was utilized to compare the effect of pharmacist interventions across 3 practice areas (medicine, hematology/oncology, and pediatrics). Two time periods were evaluated: preimplementation (PRE) and a pilot period, postimplementation of interventions (POST). Interventions included targeted discharge services, such as discharge prescription writing (with provider cosignature). Participating pharmacists completed semistructured interviews following the pilot. Results: A total of 924 patients (466 PRE and 458 POST) were included in the analysis. The median LOS decreased from 4.95 (interquartile range = 3.24-8.5) to 4.12 (2.21-7.96) days from the PRE versus POST groups, respectively ( P < 0.011). There was no difference in readmission rates between groups (21% vs 19.1%, P = 0.7). Interviews revealed several themes, including positive impact on professional development. Conclusion and Relevance: This pilot study demonstrated the ability of pharmacist interventions to reduce LOS. Pharmacists identified time as the primary barrier and acknowledged the importance of leaders prioritizing pharmacists’ responsibilities. This study is novel in targeting LOS, providing a value-based outcome for clinical pharmacy services.

Oncology research protocol design has become increasingly complex. Investigational medications used in chemotherapy, both i.v. and oral agents, are being used in conjunction with standard-of-care treatment regimens. In addition, treatments often occur over multiple clinic or hospital visits. The

Purpose The workflow and chemotherapy preparation turnaround times at an adult infusion clinic were evaluated to identify opportunities to optimize workflow and efficiency. Methods A three-phase study using Lean Six Sigma methodology was conducted. In phase 1, chemotherapy turnaround times in the adult infusion clinic were examined one year after the interim goal of a 45-minute turnaround time was established. Phase 2 implemented various experiments including a five-day Kaizen event, using lean principles in an effort to decrease chemotherapy preparation turnaround times in a controlled setting. Phase 3 included the implementation of process-improvement strategies identified during the Kaizen event, coupled with a final refinement of operational processes. Results In phase 1, the mean turnaround time for all chemotherapy preparations decreased from 60 to 44 minutes, and a mean of 52 orders for adult outpatient chemotherapy infusions was received each day. After installing new processes, the mean turnaround time had improved to 37 minutes for each chemotherapy preparation in phase 2. In phase 3, the mean turnaround time decreased from 37 to 26 minutes. The overall mean turnaround time was reduced by 26 minutes, representing a 57% decrease in turnaround times in 19 months through the elimination of waste and the implementation of lean principles. This reduction was accomplished through increased efficiencies in the workplace, with no addition of human resources. Conclusion Implementation of Lean Six Sigma principles improved workflow and efficiency at an adult infusion clinic and reduced the overall chemotherapy turnaround times from 60 to 26 minutes.

Pharmacy practice models that foster pharmacists' accountability for medication-related outcomes are imperative for the profession. Comprehensive medication management (CMM) is an opportunity to advance patient care.The objective of this study was to evaluate the impact of a CMM practice model in the acute care setting on organizational, patient, and financial outcomes.Three adult service lines focused on at-risk patients identified using internal risk stratification methodology were implemented. Core CMM elements included medication reconciliation, differentiated clinical pharmacy services, inpatient MTM consultations, discharge services, and documentation. Mixed methods compared the effect of the CMM model before and after implementation. Historical patients served as comparative controls in an observational design. Pharmacists completed a 60-minute interview regarding their experiences. Qualitative data were analyzed using thematic coding to characterize perception of the model.Three pharmacists implemented the model on cardiology, hematology/oncology, and surgery transplant services and provided services to 75 patients during the study. A total of 145 medication-related problems were identified and resolved. CMM was associated with a nonsignificant reduction of 8.8% in 30-day hospital readmission rates ( P = 0.64) and a 24.9% reduction in 30-day hospital utilization ( P = 0.41) as well as a significant reduction of 86.5% in emergency department visits ( P = 0.02). Patients receiving discharge prescriptions from our outpatient pharmacies increased by 21.4%, resulting in an 11.3% increase in discharge prescription capture and additional revenue of $5780. Themes identified from qualitative interviews included CMM structure, challenges, value, and resources.This study demonstrated successful implementation of a CMM model that positively affected organizational, patient, and financial outcomes.

Employee engagement is a method used in the workplace to ensure that employees are committed to their organization’s mission, vision, and goals.[1][1]–[4][2] Positive engagement improves employee performance and efficiency, which contribute to an organization’s overall success.[5][3] Engaged

The delivery of an accurate dose of a compounded sterile product (CSP) is paramount to ensuring effective treatment and preventing patient harm. Cases of patient harm due to errors in the production of CSPs have been widely documented.[1][1] An observational study at 5 U.S. hospitals that prepare

Background: Drug manufacturers change distribution models based on patient safety and product integrity needs. These model changes can limit health-system access to medications, and the financial impact on health systems can be significant. Objective: The primary aim of this study was to determine the health-system financial impact of a manufacturer’s change from open to limited distribution for bevacizumab (Avastin), rituximab (Rituxan), and trastuzumab (Herceptin). The secondary aim was to identify opportunities to shift administration to outpatient settings to support formulary change. Methods: To assess the financial impact on the health system, the cost minus discount was applied to total drug expenditure during a 1-year period after the distribution model change. The opportunity analysis was conducted for three institutions within the health system through chart review of each inpatient administration. Opportunity cost was the sum of the inpatient administration cost and outpatient administration margin. Results: The total drug expenditure for the study period was $26 427 263. By applying the cost minus discount, the financial effect of the distribution model change was $1 393 606. A total of 387 administrations were determined to be opportunities to be shifted to the outpatient setting. During the study period, the total opportunity cost was $1 766 049. Conclusion: Drug expenditure increased for the health system due to the drug distribution model change and loss of cost minus discount. The opportunity cost of shifting inpatient administrations could offset the increase in expenditure. It is recommended to restrict bevacizumab, rituximab, and trastuzumab through Pharmacy & Therapeutics Committees to outpatient use where clinically appropriate.

As the use of oral chemotherapy continues to rise, the issue of patient adherence is a concerning aspect of cancer treatment. In this concurrent prospective and retrospective study, we assessed oral chemotherapy adherence in patients receiving their prescriptions at an institutional specialty pharmacy, with an integrated oral chemotherapy program. The primary endpoint is medication possession ratio. Secondary endpoints include self-reported adherence comparing survey data before and after the introduction of the oral chemotherapy program to assess the impact of the comprehensive pharmacy services provided. Patients receiving their oral chemotherapy from the institutional specialty pharmacy have a mean medication possession ratio of 0.92, indicating excellent adherence rates. The oncology clinical pharmacist, in collaboration with the specialty pharmacy, has also decreased the rates of patient-reported non-adherence.

Pharmacists can expand their role by taking further responsibility in patient outcomes and strengthening the direct patient–pharmacist relationship.[1][1] Advocacy efforts are currently underway for pharmacists to be federally recognized as licensed independent providers (LIPs) and receive

Research has shown that mentoring influences career choices and can positively affect personal development, mentee self-confidence, and research productivity.[1][1] In healthcare, mentoring can be crucial for the development of future leaders.[2][2] A formal mentorship program can ensure that

Purpose The initiation, implementation, and benefits of a longitudinal early immersion student pharmacist health system internship are described. Educational activity A two-year longitudinal internship experience was implemented to provide exposure into distributional operations, direct patient care activities, and health-system pharmacy administration. The intent of the program was to create an opportunity for student pharmacists to enhance the quality of their education with practical experience by immersing them early in their careers within the healthcare system. Early in their academic training the student interns were exposed to a broad range of services and programs while contributing longitudinally to the service line through quality improvement projects and distributional operations. The first year primarily focuses on distributional operations with direct patient care shadowing, while the second year targets intern involvement in hematology/oncology direct patient care activities. In this role, they are able to serve as pharmacist extenders. Summary Our comprehensive, longitudinal two-year health-system pharmacy internship program offers student pharmacists a unique early immersion experience that builds upon itself throughout their didactic training but is outside of the academic requirements. Students are exposed to distributional operations, direct patient care activities, and health system pharmacy administration prior to APPE rotations.

Anticoagulation reversal is a time-sensitive intervention for the prevention of life-threatening hemorrhagic events occurring with bleeding or surgery. Recommendations for the most effective and well tolerated reversal agent in these settings remain controversial. Several clinical guidelines for the management of intracerebral hemorrhage support use of prothrombin complex concentrates (PCCs) for the rapid reversal of warfarin-associated coagulopathy despite limited clinical data. The purpose of this investigation was to evaluate the efficacy and safety of PCC for the rapid reversal of anticoagulation by vitamin K antagonists for life-threatening bleeding or emergent surgery and to assess adherence to a hospital-based protocol. A retrospective chart review was conducted of adult patients receiving PCC for the reversal of anticoagulation. Patients were assessed according to indication for anticoagulation reversal. The primary outcome measure was adequacy of international normalized ratio reversal. Other outcomes included cessation of bleeding, thrombotic complications, and adherence to an institutional-based guideline for the use of PCC. ICU and hospital length of stay and 30-day mortality was assessed. There were 70 patients included in this study. Mean international normalized ratio was reduced from 3.1 to 1.6 following administration of at least one dose of PCC. Cessation of bleeding occurred in 65.7% of patients. Clinical assessment was unclear in 18.6%. Thrombotic complications were observed in 7.1% of patients. The 30-day mortality rate was found to be 14.3%. These data demonstrate that PCC is a well tolerated and effective method for anticoagulation reversal associated with a relatively high 30-day survival rate.

To examine student outcomes associated with the Student Medication and Reconciliation Team (SMART) program, which was designed to provide second-year student pharmacists at the University of North Carolina (UNC) Eshelman School of Pharmacy direct patient care experience at UNC Medical Center.Twenty-two second-year student pharmacists were randomly selected from volunteers, given program training, and scheduled for three 5-hour evening shifts in 2013-2014. Pre/post surveys and reflection statements were collected from 19 students. Data were analyzed with a mixed methods approach.Survey results revealed an increase in student self-efficacy (p0.05) and positive perceptions of SMART. Qualitative findings suggest the program provided opportunities for students to develop strategies for practice, promoted an appreciation for the various roles pharmacists play in health care, and fostered an appreciation for the complexity of real-world practice.Early clinical experiences can enhance student learning and development while fostering an appreciation for pharmacy practice.

Purpose The experience of health-system pharmacy administration (HSPA) residents in a longitudinal human resource (HR) management program is described. The subsequent benefits to the residents, department, and profession are also discussed. Summary Postgraduate year 2 HSPA residents at an academic medical center desired more responsibility for managing an operational area. To this end, a program was created in which these residents directly manage a small group of pharmacy technicians and report to a clinical manager or assistant director with oversight responsibility. These “resident managers” are responsible, under the direction of the area’s clinical manager, for the personnel, schedule, time and attendance, and HR activities of the area. Resident managers have led and sustained operational improvement projects in their areas. In addition to providing learning experiences to residents, the HSPA residency program has also improved the operations of the areas in which these residents work. Benefits to the residents include conducting annual performance evaluations for employees with whom they have a relationship as it is a task every administrator completes. Resident managers at UNC have consistently stated that this longitudinal HR experience is one of the most rewarding and most challenging experiences offered in the two-year HSPA residency. The involvement of HSPA residents in longitudinal management responsibilities furthers residents’ leadership success by providing trained managers who are ready to immerse themselves into practice postresidency, having employee engagement and HR skills as well as experiences with leading operational improvements. Conclusion A longitudinal HR management experience was successfully incorporated into an HSPA residency combined Master of Science degree program.