Concepts in Measurement for Hospital Based Pharmacies Michael R McDaniel, R.Ph., MBA, FASHP Director of Pharmacy Services Huntsville Hospital, Huntsville,

Concepts in Measurement for Hospital Based

Pharmacies

• Michael R McDaniel, R.Ph., MBA, FASHP• Director of Pharmacy Services• Huntsville Hospital, Huntsville, Alabama

About Us• Huntsville Hospital

o 941 bedso 40,000 dischargeso 80,000 adjusted dischargeso 525 ADCo 180,000 outpatient visits

• The Pharmacyo Inpatient pharmacy – 142 ftes

• Oncology satellite off campus• Main pharmacy• Women’s and Children’s pharmacy

o Outpatient pharmacy, retail based – 3 sites, 8,000 monthly Rx’s, 20 fte’so Automation

• Pyxis 4000 – 160 locations (includes OR)• PhACTS carousels – 2 vertical and 2 horizontal• Health Robotics (Aesynt) IV Station and IV Soft Assist

What are we going to cover?

• Measuremento Financialo Operationalo Productivity

• Toolso Use of spreadsheetso Use of MS Access

• Datao How to collecto How to manage

• Conceptso Analyzingo Sharing

Why Measure?• Measurement is a vital management necessity• Without measurement

o You don’t know where you areo You don’t know where you are goingo You don’t know if you’ve arrived at a goalo You can’t set realistic goals

• Without measurement you can’t respond to perceptions from others accurately

• Without accurate measurement you can’t hold others accountable

• Measurement allows you to hear the “voice of the process” and take appropriate measures

• Measurement is integral to the process improvement journey• Measurement is the GPS for any organization

PatientsNurses

Physicians

Clinical Process

Order Review Process

Drug Distribution Process

Product Procurement, Storage and Preparation Process

Departmental Focus is to Serve

PharmacyThe Four Core Processes

In all things - SAFETY

FoundationsTechnician

Driven

Technician Driven

Pharmacist Driven

Pharmacist Driven

PHARMACY

But this is what pharmacy looks like to an administrator!

Landscape• From the data sources mentioned we have

created a variety of MS Access 2010 databases, many of whom talk to each other (relational)

• Data is imported from the sources monthlyo Electronic data acquisition is easier and more reliable than manually

collected data

• Reports are synthesized from the data• When necessary data from more than one

sources is used• MS Access allows linking data in different

databases thus allowing you to leverage the utility of the data

Roadmap• Productivity• Financial• Operational

Productivity• External Measurement

o Soluciento Lazarus Report

• Internal Measuremento Worko Man-hourso Ratios

• Per location• Per patient volume

• Locationso Main Hospitalo Women’s and Children’s Facilityo Madison Hospital

• Pharmacist vs. Technician measures

External Benchmarking

• Same data as the standard report, but presented in a different fashion for the audience I intend to have receive it.

• Highlights two key features both visually and with datao At the bottom of staffingo 7th percentile against a system

goal of 25th percentileo This particular quarter was much

lower than normal, we are usually around the 15th percentile

• Simpler format than the native report

• I know this does NOT help those of you at the 80th percentile!


• Two benchmarking tools allow you to see the “rest” of the story• Here we can see how we compare against true “community” peers

versus true “University” hospitals• Allows a “reality” check and keeps us grateful for the Solucient peer

groupo As a very large and complex non-academic community teaching facility we don’t neatly fit into a

“standard” groupo There are very few non-academic teaching facilities our size

• Helps keep us mindful of what data an external consultant might present us with

The Lazarus ReportHuntsville Hospital Staffed Beds

Component 25% 50% 75% 25% 50% 75% HH Staffing2013 800

Pharmacists 5.0 6.3 7.9 7.6 8.7 10.0 8.6 69Technicians 4.8 6.2 7.5 7.1 9.3 11.4 8.2 65.47Administrative 0.8 1.2 1.7 0.9 1.3 1.7 1.0 7.9Residents 0.5 0.6 0.9 0.7 1.3 2.1 1.0 8Total 11.1 13.6 18.0 16.4 19.4 25.2 17.8Variance -6.7 -4.2 0.2 -1.4 1.6 7.4 -144.5FTE Variance -53.97 -33.81 1.23 -11.01 12.43 59.15

Community - Percentile University - Percentile


• This is about the extent of my external benchmarking work

• Solucient does not play a very active role in our staffing maintenance

• This may not be the same for you• My experience in my 3 large facilities where I’ve served

as a Director has been that internal productivity measurement have been more important to my daily life as a manager.

• The keys to surviving external benchmarking are:o Have the right compare group

• Our compare group are large, highly complex facilities which, except for our lack of a solid organ transplant program, I feel we compare very well to

o Have the right workload benchmark• CMI Adjusted Discharges – better• Doses - worse

Internal Productivity Monitoring

• Provides intelligence as too The work actually doneo How many resources this work consumeso Who is doing ito And how this all changes over time

• Internal productivity monitoring is vital too Assess reality vs. perceptions on

• Administration’s point of view• Pharmacy Leadership’s point of view• Staff’s point of view

• Allows you to assess the appropriateness of moving resources from one function to another

Internal Measurement





• This data allows us to examine our allocation of resources for internal process improvement efforts

• It also positions us with data to counter or confirm the recommendations of external consultants should that day come

Internal Measurement• Drill down

capability is needed for the “next question”

• This report drills into our clinical activity

• Allows us to quickly find what we are spending our time on

Internal Measurement• Another drilldown

allows us to review overall clinical activity by individual pharmacist

• Its important to look at the opportunities each pharmacist has to avoid an apples to oranges comparison

Internal Measurement• Another angle on

individual clinical productivity

• These two reports are used by the respective supervisors to monitor clinical productivity

• The trends can be interesting

• Fun to watch new pharmacists emerge out of training and gain experience and confidence

Internal Measurement• Yet another level

of drilldown• We can review

the different types of work done, including clinical activity

• We can also contrast the various job classes against each other

Roadmap• Productivity

• Financial• Operational

Financial Measurement

• Financial analysis for many of us means explaining drug budget variances

• Many variables affect this numbero Inpatient volumeso Outpatient volumeso Patient mix

• Length of stay = more doses delivered!


• I’ve found that some of my most expensive patients are outpatientso Oncologyo IVIGo Specialty drugs

• Monitoring the ratio of inpatient discharges to OP visits helps me detect an increase in the potentially high cost outpatients


• This report details the use of IVIG for a 5 quarter period

• From this I can see where the IVIG was used, Inpatient vs. Outpatient

• This is valuable for 340B hospitals and to pick up changes in utilization between these two classes


• From the same set of data I can see the trend over time

• Our patient volumes related to IVIG have declined


• This “ugly” graph of our drug spend trend shows our unadjusted drug spend since 2005

• As Superman would say “Up, up and away!”

• What this shows is:o Significant IP growtho Significant OP growtho Huge increase in IVIG

volumes

• But what is happening now?

FY 2005

FY 2006

FY 2007

FY 2008

FY 2009

FY 2010

FY 2011

FY 2012

FY 2013

FY 2014

FY 2015

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

$45,000,000

Net Drug Spend


• Volume adjustments can make a HUGE difference

• Here is what our volumes look like, probably much like yours

• Inpatient volumes show the impact of the recession

• Outpatient volumes – through the roof for a while, then co-pays!

• Adjusted discharges remain healthy

FY 2005

FY 2006

FY 2007

FY 2008

FY 2009

FY 2010

FY 2011

FY 2012

FY 2013

FY 2014

FY 2015

60,000

80,000

100,000

120,000

140,000

160,000

180,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000 Patient Volumes

Outpatient Episodes Discharges Adjusted Discharges

Fiscal Year

Ou

tpat

ien

t E

pis

od

es

Dis

char

ges

/ A

dju

sted

Dis

char

ges


• So after volume adjustments the drug spend trend is a little clearer

• You can see the impacts as outlined below (primary drivers, not exclusive)

• Drug shortages also figure in

• Adjusted discharges have fluctuated in a narrow range since 2010

• To what do we owe this latest upsurge to

FY 2005

FY 2006

FY 2007

FY 2008

FY 2009

FY 2010

FY 2011

FY 2012

FY 2013

FY 2014

FY 2015

$200

$250

$300

$350

$400

$450

$500

$550

$600

$650

$700

$-

$20

$40

$60

$80

$100

$120

$140 Drug Expense per Statistic

Calc'd Inpatient Cost Per Disch Calc'd Cost per Adj Disch Calc'd Outpatient Cost Per Visit

Period

Co

st p

er D

isch

arg

e

Co

st p

er O

P V

isit

IVIG

Oncology


• By tracking all of our medication purchases by their AHFS class, and grouping these classes into “mega” groups we can start to drill into where the changes are occurring

• Anti-neoplastic, cardiovascular and Other Pharmaceuticals really stand out

Pharmacy Drug Spend Trends AnalysisComponent FY 14 FY 15 Delta Prior Year

Anti-Infectives 7,038,556$ 7,691,636$ 9.3%Antineoplastics 2,642,882$ 3,320,128$ 25.6%Autonomic Drugs 1,578,237$ 1,662,600$ 5.3%Blood Products 6,404,431$ 6,655,548$ 3.9%Cardiovascular 1,143,689$ 1,430,180$ 25.0%Central Nervous System 3,441,326$ 3,265,620$ -5.1%Gastrointestinal 993,639$ 1,026,592$ 3.3%IVIG 6,235,010$ 5,921,416$ -5.0%Other Pharmaceuticals 6,657,142$ 9,232,544$ 38.7%Storeroom 1,199,361$ 1,221,368$ 1.8%Unclassified Therapeutic 2,846,375$ 3,381,476$ 18.8%Totals 40,180,648$ 44,809,108$ 11.5%Adjusted Discharges 79,404 82,192 Anti-Infectives 88.64$ 93.58$ 5.6%Antineoplastics 33.28$ 40.39$ 21.4%Autonomic Drugs 19.88$ 20.23$ 1.8%Blood Products 80.66$ 80.98$ 0.4%Cardiovascular 14.40$ 17.40$ 20.8%Central Nervous System 43.34$ 39.73$ -8.3%Gastrointestinal 12.51$ 12.49$ -0.2%IVIG 78.52$ 72.04$ -8.3%Other Pharmaceuticals 83.84$ 112.33$ 34.0%Storeroom 15.10$ 14.86$ -1.6%Unclassified Therapeutic 35.85$ 41.14$ 14.8%Totals 506.03$ 545.18$ 7.7%


• Drilling down into “Other Pharmaceuticals” we find that the AHFS category called Enzymes is up the most

• This report shows the activity for the same time period

• Idursulfase is the winner


• We find the spend pattern for idursulfase

• Very consistent usage• Checking our charge

history we find this one drug is used by just one patient

• This is becoming an increasingly common occurrence


• Take a step back and look at the macro view every now and then.

• Adjusted for volumes, pharmacy has been very flat over the past several years

• This is a GOOD thing


• Worked and paid hours are a focus

• In this environment, the flatter this line, the better!

• The statistic is adjusted discharges

Roadmap• Productivity• Financial

• Operational

Operational Measurement

• We have to balance our staff between two buildings / pharmacies that function as wildly different facilities

• Adult – intensive care

• Pediatric intensive and women’s care


• This data helps to analyze the balance between our shared facilities

• W&C is “over-staffed” due to its heavy pediatrics volume and complexity

Period Ending 3/31/14 Main W&C MadisonPharmacy Adjusted Discharges 22,941 12,307 2,756 CMI 1.9297 0.8976 1.1219 CMI Pharmacy Adjusted Discharges 44,268 11,046 3,092 Scheduled Hours Pharmacists 43,451 9,963 Scheduled Hours Technicians 32,752 17,218 Total Worked Hours 76,203 27,181 5,643 Per CMI Pharmacy Adjusted Discharge 1.72 2.46 1.83


• Pyxis is a huge job for our technicians

• We keep a close eye on what it takes to feed the monster!


• We have a variety of reports we can use to monitor this process

• This report looks at the resource requirements for each location, each day

• This can serve as a baseline for PDCA efforts


• This report allows a more macro view of the Pyxis environment


• We monitor our carousel traffic as well


• We track the utilization trends

• Can you guess when our big Pyxis batch is run?


• This is an example of a daily carousel detail report looking at:o Pyxis batch datao Receivingo Ins and outs by

locationo Activity by type

• Gives good insight into the carousel


• One of the things we measure for order review is orders per hour

• We do this by facility and by day of week


• We can drill down to the individual pharmacist and by shift


• Another interesting macro view over time

• Measures the total orders processed per discharge for a given month

In Closing• Much of this data, when appropriate, is shared

both internally and externallyo Internally to monitor our processes and lay a foundation for

improvemento Externally to answer various questions about financial or productivity

performance

• The relative quickness and ease of our responses externally gives a strong impression of “being on top of things” or “being in the know” which are important confidence builders in administration’s eyes

• This data allows for the building of comprehensive and accurate business plans

In Closing• Look for data that already exists, capture it, and

put it to work• Be judicious in performing manual data collection

o It is work in its own righto It can be hard to do accuratelyo But sometimes it must be done

• Data never lies, but it can mislead!o Look for the larger contexto Try to use at least 2 points of view before coming to a conclusion about

what data is telling you

• Manage and manipulate the data carefully, but recognize that most data is worthless until properly managed or manipulated

Documents

Concepts in Measurement for Hospital Based Pharmacies Michael R McDaniel, R.Ph., MBA, FASHP Director of Pharmacy Services Huntsville Hospital, Huntsville,