Reaching New Heights through Pharmacy Technician Advancement

Ross Thompson, M.S., R.Ph.

Director of Pharmacy Services

Melissa Ortega, M.S., Pharm.D.

Pharmacy Operations Manager

1

Objectives

1. Review ASHP Pharmacy Practice Model Initiative (PPMI)

2. Discuss methods for evaluating your practice setting

3. List PPMI recommendations on technician advancement

4. Highlight methodologies for facilitating practice change

5. Discuss ASHP and MSHP initiatives to facilitate change

2

PPMI Vision and Goals

Vision of PPMI

To create passion, commitment, and action among hospital and health-system pharmacy practice leaders to advance the health and well being of patients by optimizing the role of pharmacists in providing direct patient care

Goal of PPMI

Implement the vision by support a futuristic practice model

Describe how resources are deployed to provide care.

•How pharmacists practice and provide care to patients•How technicians are involved to support care•Use of automation and technology

AJHP 2010;67:5423

Translating Recommendations Into Practice

• 106 Recommendations

• ASHP Publications• Policy• Tools• Research

4

5

Categories of Self-Assessment Criteria

I. Hospital DemographicsII. Optimal Practice Model Characteristics (organization)III. Optimal Practice Model Characteristics

(employee/scope)IV. Advancing Information TechnologyV. Advancing Pharmacy Technician RolesVI. Successful Implementation of New Practice model

6

Benefits of Completing a Self-Assessment

• Identifies gaps• Assists with prioritization• Generates an action plan • Links to resources supporting the recommendation• Tracks performance / conformity• Provides comparison with other hospitals

7

Optimal Pharmacy Practice Model Characteristics – Part I

Are pharmacists recognized for taking a lead role in providing drug therapy management services to patients at your hospital/health system?

12% Exists in all areas/situations (100%)

50% Exists in most areas/situations (50-99%)

38% Exists only in some areas/situations (1-49%)

0% Does not exist (0%)

0% Not applicable

Definition: Drug Therapy Management is a multidisciplinary team process for selecting appropriate drug therapies, educating patients, monitoring patients, and continually assessing outcomes of therapy. Pharmacist activities in drug therapy management may include, but are not limited to: initiating, modifying ,and monitoring a patient’s drug therapy; ordering and performing laboratory and related tests; assessing patient response to therapy; counseling and educating a patient about medications; and administering medications.

8

Optimal Pharmacy Practice Model Characteristics – Part II

Is medication reconciliation performed by the pharmacy staff at your hospital/health system?

4% Medication reconciliation is performed by pharmacy staff throughout all areas

8% Medication reconciliation is performed by pharmacy staff in some areas

38% Medication reconciliation is partially performed by pharmacy staff in some or all areas

46% Medication reconciliation not performed by pharmacy staff

4% Not applicable

9

Optimal Pharmacy Practice Model Characteristics – Part II

If you employ pharmacy student interns, are their duties different from traditional pharmacy technician duties?

50% Yes

38% No

12% Not applicable

10

Advancing the Application of IT in the Med Use Process

Has clinical decision support been integrated with computerized provider order entry at your hospital/health system?

23% Exists in all areas/situations (100%)

31% Exists in most areas/situations (50-99%)

27% Exists only in some areas/situations (1-49%)

15% Does not exist (0%)

4% Not applicable

11

PPMI Results: Massachusetts

• Total of 1,025 organizations have submitted data• Overall score of 52% compliance with

recommendations

• Northeast region has 171 organizations scoring at 50%

• Includes 26 of approximately 100 Massachusetts facilities

• Massachusetts facilities collectively scored 51%

• Advancing technicians’ role is the nation’s lowest score at just 28% compliance with recommendations

12

Initiating the Change Effort at Tufts MC

13

What to Prioritize

• Total Score: 54%– Optimal Pharmacy Practice Model Characteristics Part 1 and

2•70% and 48% (66% and 41% nationally)

– Advancing the Application of IT in the Medication Use Process•45% (46%)

– Advancing the Use of Pharmacy Technicians•44% (28%)

– Successful Implementation of New Pharmacy Practice•52% (60%)

• Items Completed: 37• Items Close to Completion: 22• Items Needing Completion: 39

14

Acute Care Pharmacy Practice Model

• Integrated Practice Model via 5 Service Delivery Teams

• Each service team will consist of 2 or 3 pharmacists, 1 resident, and 1 technician on day shift; then either 1 or 2 pharmacists on weekday evening and weekend day shifts

• Each service team is responsible for providing our complement of services to a specific patient care area

15

How We Will Structure Our Acute Care Services

• Team based practice model: specialist, generalists, technician, resident, and student

• Pharmacist time devoted to clinical services– Pharmacy core services provided to every patient, every

day– Targeted services for high risk or complex patients /

therapies• Drug distribution facilitated by pharmacy

technicians

16

Creating a Vision

17

Vision Statement

Members of the Tufts Medical Center Department of Pharmacy Services are sought after for their expertise and are

accountable for medication therapy outcomes; providing the best possible

care for every patient, every time.

18

Pharmacy Practice Councils

•Four Councils•Chaired by staff •Wrote Charter•Establish goals•Plan and make change

19

Change Management Overview States and Phases

Change is a process

Themes can be categorized into 3 states

Current

State

Transition

StateRemedy/Vision

DesiredState

Pain/Urgency

20

“If you don’t like change, you are really

going to hate being irrelevant”- Tom Peters

The status quo is not an option!

21

Change Models Key Principles

Documented in the literature with success in various settings

BusinessNon-profit associationsHealthcare organizations

Types of change models8 steps of change managementHealthcare redesign and improvement models Pharmacy specific

Ray MD, Breland BL. Am J Health-Syst Pharm—2011;68:1138-4522

Change Models help you think about…

• The what, why, and how to make it work for technicians and pharmacists in a new world

• Where to start?• What are the best practices in raising the bar

for technician roles?• Who are the key stakeholders?• What are the barriers and challenges?• Inter professional relationships on the front

lines-what works what doesn’t when roles change?

• How to get buy-in?• Resources to build advanced technician

workforce – where to go and how to use?• What are the one or two keys to your success?• What will you measure to demonstrate value?

23

1. Create Urgency

2. Form a Powerful Coalition

3. Create a Vision for Change

4. Communicate the Change Vision

5. Remove Obstacles

6. Create Short-Term Wins

7. Build on the Change

8. Anchor the Changes

Kotter’s 8-Step Change Model

Leading Change, John P. Kotter, HBR, 199824

The 8 Step Approach to

Leading Change Applied:

Mobilizing Practice Change: Advancing the pharmacy practice model through a

technician advancement council

Kotter JP. Leading Change: Why Transformation Efforts Fail. Harv Bus Rev. 1995;59-67.

Leading Change, John P. Kotter, HBR, 199825

• Helping others see the need for change and the importance of acting quickly

• Convince at least 75% of your people that the status quo is more dangerous than the unknown

Tufts Medical Center’s Actions:• Distribute appropriate background materials and highlight

gaps • Examine the best practices & understand the literature • Establish structure around initiative Potential Pitfalls:• Underestimating the difficulty of driving people from their

comfort zones• Becoming paralyzed by risks

Step One: Create Urgency

26

ASHP PPMI Tuft’s Action Plan

Recommendations Tufts Impact Feasibility

Are all distributive functions that do not require a pharmacist's clinical judgment assigned to technicians at your hospital? D9

No

Have pharmacy technician responsibilities been expanded to the extent possible based on education and training at your hospital? E4e

No

Is the management of medication assistance programs assigned to pharmacy technicians who have appropriate education and training at your hospital? D3k

No

Is the supervision of other pharmacy technicians assigned to technicians who have appropriate education and training at your hospital? D3n

Some areas/ situations

Is the management of pharmacy department information technology systems, including routine database management and billing systems, assigned to pharmacy technicians who have appropriate education and training at your hospital? D3m

Some areas/ situations

Is initiation of medication reconciliation , including obtaining and documenting patient medication information for pharmacist review, assigned to pharmacy technicians who have appropriate education and training at your hospital? D3a

Some areas/ situation

High Impact:High Feasibility:

Identify Gaps

27

Areas of Opportunity for Technicians

Am J Health-Syst Pharm—Vol 68 Oct 1, 2011UHC Practice Advancement Committee Survey*: Areas of Opportunity for Technician Deployment- Apr 2012

Examine Best Practices and Literature

Survey Themes

Less than 50% More than 75%• Maintenance of computer

system software (40%)

• Medication safety functions (37%)

• Leadership roles (28%)• Supervising other

technicians

• Technician checking (tech-check-tech) (32%)

• Conducting aspects of the quality improvement programs and/or quality assurance program (31%)

• Initiation of medication reconciliation (18%)

• Collection patient data (i.e., labs, insurance information, etc.) (18%)

• Criteria based screening of medical records (18%)

• Evaluating clinic-administered medication for reimbursement (11%)

• Collect and summarize data for department dashboard (21%)

• Purchasing/inventory management/contract/Drug shortage management (85%)

• Maintenance of medication storage (satellites, unit med rooms, medication bins) (88%)

• Audits (79%)

• Sterile product and Non-sterile product compounding (99%)

28

Pharmacy Councils

29

Technici

an A

dvancemen

t

• Utilize the current technician workforce to help manage the growing complexities of the medication use system

• Reassign medication distribution tasks to pharmacy technicians Redeploy pharmacists time to drug therapy management activities and direct patient care activities

• Maintain a competent pharmacy technician workforce

• Develop opportunities for technician specialization

• Incorporate technicians within the team based practice model

Operations Improv

em

ents

•To place an emphasis on optimizing coordination between central operations and procurement to gain efficiencies to realign resources for decentralization of technicians

Phar

macy Pr

actice Advanc

emen

t

•To design and implement activities that allow pharmacists to extend their scope of practice and maximize their contributions to patient care. This will incorporate the progress made by a current workgroup that will now include representation from the Cancer and Pediatrics service teams.

Traini

ng an

d Develop

men

t

•Account for training needs as staff assume new responsibilities, formalize structured programs for new employee training as well as annual training to address needs across the department.

Establish Structure Around Initiative

Change Management Style- Finding the BalanceEstablish Structure Around Initiative

Tight Loose Tight Participative and

authoritarian Delegative and

participative Blend of authoritarian

and participative

I. Set goals tightlyII. Be articulate and

comprehensive

I. Allow the team to figure it out and trust in their knowledge, skills and ability

II. Delegate appropriately

I. Measure results tightly

II. Ensure accountability

30

Technician Advancement Council

Council’s Charter 1. Positions

Facilitator Chair Liaisons

2. Objectives3. Deliverables4. Outcomes

GuidelineExpectations

Minutes and agendasParticipation and attendance

Establish Structure Around Initiative

31

• Identify key stakeholders, educate them and build their interest and support

Tufts Medical Center’s Actions:• Assemble a group with shared commitment and enough

power to lead the change effort• # technician members > # pharmacist members

> # administrative members

• Identify and meet with stakeholders

Potential Pitfalls:• No prior experience in teamwork at the top

Step Two: Form a Powerful Coalition

32

Tufts Medical Center’s Experience

Sterile Product Area Lead Technician

• Coordinates training and annual validation/surveillance of aseptic technique• Manage responsibilities, training, and workflow• Projects: QA Program 2013 and IV workflow Fall 2013

Automation and Distribution Technician

• Oversees support systems to maintain automated dispensing cabinets (ADC) • Understands and independently uses, oversees, and troubleshoots issues• Coordinates software upgrade or hardware exchange • Project: Hospital-Wide ADC upgrade 2012

Informatics Technician

• Oversees and maintains databases • Compiles and analyzes workload statistics • Project : Carousel Automation and Split-Billing Software 2012-2013

Triage Lead Technician

• Holds technician staff accountable for performance • Oversight of med room unit inspection and ensure continuous survey readiness• Coordinates and composes schedule• Project: Pharmacy One source Upgrade 2012

33

Examples of Advanced Technician Roles

Council Membership

• Council Membership and representation – 12 members

• Technicians (8)• Pharmacist (3)• Chair

– Technician• Facilitator

– Manager • Ad Hoc Nurses

– Stakeholders• Pharmacists • Nurses• Technicians

Pharmacy Technicians

Core Areas of Practice

34

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.”

– Margaret Mead

35

• Create a picture of the future & how it will be different from the past

• Use every vehicle possible to constantly communicate the new vision & strategies

Tufts Medical Center’s Actions:• Establish the vision = Council’s Objective• Strategy for realizing the vision

• Analyze and plan • Council work

Potential Pitfalls:• Presenting a vision that’s too complicated• Under-communicating the vision

Step Three & Four:Create and Communicate a Vision for Change

36

Putting it all together…

“Vision without action is simply dreaming”

• Council’s Objectives– Expand the role of team based technicians– Create opportunity for pharmacy technician

specialization– Maintain competent workforce to manage growing

complexities of the med use system

Establish the Vision

37

Strategies for Achieving the Vision Analyze and Plan

• List expected changes within the next two years – Team based technicians – Tech-Check-Tech

• Perform current state analysis – Define each technician’s role

• Date Collection Log

• Review internal results– Current state analysis vs pilot project

38

High Impact/Importance

Example of activities Valued Activities

1. Face to face interaction with nurses, doctors, and other medical professionals on a daily basis

2. Compound sterile and non sterile medications

3. Maintenance of automated dispensing cabinet (ADC) inventory (loading, unloading, refilling) and pulling expired medications

4. Assist nurses with missing doses and ADC trouble shooting

5. Deliver medications to clinical areas (routine meds and/or stat meds and/or high cost meds)

6. Vault / controlled substance retrieval and delivery

7. Clean-Up Run: med room organized, check census, return meds

8. Process missing meds, purchasing drugs and supplies

9. Unit dose packaging/maintenance/dispensing

10.Complete charging/crediting

Activities currently being performed

39

• Align information, systems and processes to the vision

• Identify resistors and help them see what is needed

Tufts Medical Center’s Actions :• Encourage risk taking and non-traditional ideas,

activities, and actions• Recognize current activities that add value

• Identify boundaries, constraints, and assumptions

• Recognize resource needs and availability

• Create a plan to overcome obstacles

Potential Pitfalls:• Failing to remove obstacles

Step Five: Remove Obstacles

40

Identifying obstacles: Council Feedback

• Questions to ask– What potential physical barriers in a pharmacy department

should be considered? – What additional education and training will individual

members need in order to implement the desired change?– What types of resistance or “push-back” might be anticipated

from pharmacist , nurses, or others outside the pharmacy

department?

Council’s ExerciseWhat can change? What cannot change:

1. Staffing Allocation 2. Responsibilities of technicians that are

not required and do not add value3. Regulations that prevent technicians

from assuming pharmacist responsibilities (may require us to apply for a Board exemption)

1. No new FTE positions-change in FTE must come from within existing resources

2. Technology resource allocation

41

Plan Overcoming Obstacles

Key elements for success Advocate for technological resources to support safe, effective, and efficient medication use system and aid the role of pharmacy technician

Collaboration with other councils

Streamline operations and reallocate resources to allow for a decentralize technician model

Operations Improvement Council

Optimize decentralized pharmacy servicePharmacy Advancement Council

Prepare, train, and educate technicians to take on new roles

Education and Training Council

42

• Plan for visible improvements in performance, or “wins”

• Create short-term targets, not just one long-term goal

Tufts Medical Center’s Actions : • Separate initiatives to deliverables

• High impact/high feasibility items• Prioritize “low hanging fruit”

• Define and engineer visible performance improvements

Potential Pitfalls:• Leaving short-term successes up to chance

Step Six: Create Short-term Wins

43

High impact & High Feasibility Items

Activities and recommendations Impact Feasibility

1. Be seen and utilized as the drug distribution expert –service based technicians

2. Communicate drug shortages or unusual utilization

3. Transfer meds with patient between units

4. Gather patient data (i.e., labs, insurance, etc.)

5. Assist with insurance / prior authorizations

6. Track med delivery from pharmacy to floor

7. Adjust inventory levels and locations in ADMs

8. Develop and use reports to prioritize workflow

9. Collect and summarize department quality data

High Impact (value-added activities):High Feasibility:

Activities NOT currently performed

44

Prioritize “Low Hanging Fruit”

2. Daily monitoring of override reports

3. Collection of and following up of written orders

6. Oversight when patient’s are transferred

1. Pulling and receiving narcotics

5. Initializing or receiving communication

• Missing doses• Medication status• High utilization • Drug shortages

7. Discharge process- insurance and prior authorizations inquiries

4. Drip Rounds-Monitoring of continuous infusions

Low hanging fruit = All distributive functions that do not require clinical judgment currently completed by a pharmacist45

Implement the Process: Create Short Term Wins

Override Reports Plan: report collected and

reviewed by technician. Do: Reallocate task - Follow up

on discrepancies with Pharmacist and/or health care provider.

Check: Number of overrides reconciled accurately

Act: Continue with plan

A P

C D

• Incremental approach versus big bang• Used the Plan, Do, Check, Act (PDCA) model to guide

implementation • High impact/high feasibility items • “Low hanging fruit”

46

• Consolidate improvements and produce more change• Leverage quick wins to build momentum for change• Communicate change, the impact and the value;

provide ongoing documentation

Tufts Medical Center’s Actions:• Build momentum for change

• Publish results (tell the story)• Demonstrate value

Potentials Pitfalls:• Declaring victory too soon

Step Seven and Step Eight:Build on the Change and Anchor the Changes

47

Tuft’s Experience Pharmacy Extenders- Team Based Technicians

• Pediatric team based technician– Responsible for specific nursing units

• Delivering IV run, oral syringes, pediatric pull, narcotics, refilling automated dispensing systems, finding missing doses, following up with stat doses

• Available by pager • Available for assisting decentralized pharmacist with request

• Metrics – Percentage decrease of pharmacist time on task of

distributive functions – Increased level communication between inpatient

pharmacy and the units – Increased communication about medication turn around

time 48

Tuft’s Experience Pharmacy Extenders- Team Based Technicians

• Lessons learned – Not everyone can be placed in roles where they need to

interact with other health care providers – Amount of autonomy– Define responsibilities and medication distribution model

clearly– New tool developed

–Pediatric performance indicator log

• Recognized benefits– Potential to reduce readmission rates, prevent

or mitigate medication errors

49

Tuft’s Experience Measure the Impact

• Recognize and reward new behavior to embed into new culture

50

When We Succeed … What Will We Have?

• Technician Advancement Council:– Empowerment to provide drug distribution services– More engaged and productive pharmacy technician

workforce– Greater accountability for customer service to team-based

units

• Department of Pharmacy– More engaged and productive pharmacist workforce– Ability to refocus time toward optimizing care or expanding

scope

• Tufts Medical Center– Improved patient satisfaction– Increased adherence and decreased readmissions

51

What Barriers are Standing in Our Way

52

We Have Met the Enemy and …

53

Who Has A Success Story to Share?

• Innovative Role for a Technician

•Exemption from the Board or the DPH

54

How Can MSHP Support Tech Advancement?

• Open Discussion

• Questions

55