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Title: What is Your Possibility: Exploring Work Life Challenges and Opportunities


1
What is Your Possibility Exploring Work Life
Challenges and Opportunities
  • Rita Shane, Pharm.D., FASHP, FCSHP
  • Director, Pharmacy Services
  • Cedars-Sinai Medical Center
  • Asst. Dean, Clinical Pharmacy
  • UCSF School of Pharmacy

2

Work Life Possibilities
Professional Goals
Having a purposeful life
Working in a progressive, clinical practice
environment
Demonstrating value by improving patient care
Balance/Peace Mind, Body, Spirit
Possibilities
Teaching
Building a family
Recognition for contributions
Loving/Caring Relationships
Personal Goals
3
Ritas Views on Balance
  • Personal and professional goals are generally not
    mutually exclusive
  • Professional commitment and rewards that come
    with it contribute to personal happiness
  • Lessons learned at work, e.g., teamwork, dealing
    with conflict, improve ones ability to deal with
    home/personal life matters
  • Home life and challenges associated with raising
    a family enable one to understand and appreciate
    people at work
  • Priorities and goals will shift on an ongoing
    basis

4
Rebalancing
5
What Does It Take?The World According to Me
  • Prerequisites and Assumptions
  • Supportive family
  • Low maintenance partner
  • Childcare arrangements
  • Most challenging part
  • Recognizing that children are at least a 25 year
    longitudinal study with no control group and no
    crossover
  • Compartmentalizing work and life

6
What Does It Take?The World According to Me
  • Prerequisites and Assumptions
  • Accepting less than a Martha Stewart household
  • Recognizing that one will make mistakes
  • Having a professional vision-what you want to
    achieve
  • Having a passion for pharmacy and for life
  • One person with passion is better than 40 people
    who are merely interested. Abigail Adams

7
Having a Professional VisionBig Hairy Audacious
Goal (BHAG)1
  • 1924 Thomas Watson
  • Computing Tabulating Recording Company renamed
    International Business Machines
  • 2005 Rita Shane
  • Wherever patients need care, there is a demand
    for pharmacists to ensure optimal management of
    medications

1. Collins JC, Porras JI. Built to Last, 1994.
8
Built to Last
  • Companies that have been in existence for at
    least 50 years and have made an indelible imprint
  • IBM, Xerox, 3M
  • Possess core ideology-values and purpose
  • Enable evolution over time as situations change
  • Anticipate market needs
  • Rebound despite setbacks
  • Have BHAGs

9
Is Pharmacy Built to Last?
  • Core ideology Improvement in patient care
    outcomes through provision of clinical services
    in all healthcare settings
  • Pharmaceutical care should be something that
    patients demand, like clean sheets and board
    certified surgeons1

1. Kepple SR. (AJHP Manuscript Editor) Invisible
Care. Am J Hosp Pharm. 1995 52888.
10
How to Achieve Your BHAG in Pharmacy
  • Big Picture Thinking
  • Exploiting Change
  • Risk Taking
  • Building Relationships

11
Big Picture Thinking
Pharmaceutical Supply Chain Integrity
Regulatory Requirements
Automation/Technology CPOE Barcoding Smart Pumps
  • Trendbending
  • How does this trend impact?
  • Healthcare
  • Patients
  • Pharmacy
  • You

Medicare Modernization Act
Quality Mandates
Increasing Heatlhcare and Drug Costs
Patient and Medication Safety
Manpower Shortages
Chronic Disease Management
Pharmaceutical Industry
12
Pharmaceutical Industry Trends
  • Drug withdrawals due to safety issues
  • Direct to Consumer Advertising
  • Research
  • Requirement to register all clinical trials as a
    result of findings that negative results were not
    being published
  • Professional Relationships with Pharmaceutical
    Industry under scrutiny
  • OIG Compliance Program for Pharmaceutical
    Manufacturers
  • Drug Shortages

13
Pharmaceutical Supply Chain Integrity
14
Increasing Healthcare Costs1
  • Healthcare cost represented 15.2 of U.S. gross
    domestic product in 2004
  • Hospital expenditures represent 32 of national
    HC spend
  • Healthcare premiums have increased 4 years in a
    row 11.2 in 2004 (inflation 2.3)
  • 59 increase in health insurance since 2001.
  • Progress in technology, ie implantable devices,
    biopharmaceuticls, non-invasive imaging,
  • Medical Malpractice
  • Manpower shortages drive up wage expenses

1. Kaiser Foundation and Health Research and
Educational Trust
15
Manpower Shortages
  • Nursing shortage
  • 12 hour shifts
  • Increased risk of errors
  • Allied health professionals
  • NPs, PAs
  • 80,000 PAs predicted by 2010 vs. 62,000 currently
  • Scope of practice
  • Physician shortage
  • MDs lt36 y.o. working 10 less than MDs gt36y.o.
  • Scheduling and work/life balance
  • Pharmacist shortage

16
Reasons for Growing Demand for Pharmacists1
  • Increased use of prescription medications
  • Increased access to health care and more health
    care providers authorized to prescribe
    medications
  • Expanded health insurance coverage
  • Increased prescriptions and time-consuming
    third-party payment tasks
  • Growing emphasis on Pharm.D., which lengthens
    education
  • The Pharmacist Workforce A Study of the Supply
    and Demand for PharmacistsHealth Resources and
    Services Administration, 2000

17
Reasons for Growing Demand for Pharmacists1
  • Strong competition for pharmacists trained at the
    residency or fellowship level
  • schools of pharmacy
  • managed care organizations
  • pharmaceutical corporations
  • hospitals
  • Increase in females in profession
  • Desire for work/life balance
  • Not just a female driven issue
  • The Pharmacist Workforce A Study of the Supply
    and Demand for PharmacistsHealth Resources and
    Services Administration, 2000

18
Rising Drug Costs1
  • Increases in Prescription Drug Expenditures
  • 15 in 2000
  • 18 in 2001
  • 12.3 in 2002
  • Predicted increase of 11.1/yr for the next 10 yr
  • Hospital Drug Expenditures
  • 9.6 increase in 2002
  • Overall drug prices increased by 11.1
    injectables increased by 13.9
  • Volume and variety decreased by 3.5
  • 2005 Forecast
  • 6-9 increase in hospitals
  • 10-12 increase in outpatient settings
  • 12-15 increase in clinics
  • Hoffman, et al. Am J Health-Syst Pharm. 149-67
    2005

19
Infusions and Injectables forChronic Disease
Management
  • 1980s-emergence of outpatient cancer centers for
    chemotherapy infusions
  • Medical injectables represent 17-20 billion/yr
    for treatment of cancer and other conditions
    (2002)1
  • Biologics and other high cost therapies-6,000-200
    ,000/pt/yr
  • 1.Specialty Pharmaceutical Benefit Management
    Roundtablewww.acmcentral.com, 2002.

20
Medicare Modernization Act
Importation
Medication Therapy Mgmt.
Prescription Benefit
Quality Measures
MMA
Formulary
Reduced Outpatient Reimbursement
Increased Drug Prices
Specialty Pharmacy
Reduced Physician Office Reimbursement
Increased Hospital Admissions
21
Medicare Part D Prescription Benefit
Donut Hole
Pt still pays monthly premium
22
Medicare Modernization Act (MMA or Medicare Part
D)
  • Mandates Medication Therapy Management Services
    by plan sponsors, effective Jan 06
  • Pts targeted multiple chronic conditions, e.g.
    asthma, DM, HTN, high cholesterol, CHF
  • Specifically states pharmacists as a provider
  • Reimbursement for services not explicit to be
    determined by drug plan sponsors
  • End of Average Wholesale Price (AWP)
  • AWP spread and implications
  • Average Sales Price to be used
  • Oncologists estimate 15 drop in drug
    reimbursement in 2005

23
Quality Mandates
  • MMA
  • Reduced if quality measures not reported as of
    2004
  • Majority of measure pertain to medication therapy
  • Acute MI
  • CHF
  • Pneumonia
  • Leapfrog Group-consortium of employers
  • National Quality Forum
  • Health Plans in California
  • Pay for Performance

24
Hospital CompareHeart Attack (AMI) Care Graphs
  • Percent of Heart Attack Patients Given
  • ACE Inhibitor for LVSD
  • Adult Smoking Cessation Advice/Counseling
  • Aspirin at Arrival and at Discharge
  • Beta Blocker at Arrival and at Discharge
  • Thrombolytic Agent within 30 minutes of arrival

www.cms.hhs.gov, posted 3/31/05
25
Percent of Heart Attack Patients Given Aspirin
at Arrival

www.cms.hhs.gov, posted 3/31/05
26
Percent of Heart Attack Patients Given Aspirin
at Arrival
  • Why is this Important?
  • The heart is a muscle that gets oxygen through
    blood vessels. Sometimes blood clots can block
    these blood vessels, and the heart cant get
    enough oxygen. This can cause a heart attack.
    Chewing an aspirin as soon as symptoms of a heart
    attack begin may help reduce the severity of the
    attack. This chart shows the percent of heart
    attack patients who were given (or took) aspirin
    within 24 hours of arrival at the hospital.

27
National Quality Forum (NQF)Pharmacy-Related
Indicators
  • Pharmacist Active Participation in Med Use
    Process
  • Prophylactic Beta Blockers for Elective Surgery
  • Standardize Abbreviations and Dose Designations
  • DVT/VTE- Risk Assessment Prevention
  • Provide Dedicated Anticoagulation Services
  • Surgical Site Infection/Antibiotic Prophylaxis

28
NQF Pharmacy-Related Indicators
  • Contrast-induced Renal Failure Protocol
  • Malnutrition Prevention
  • Flu Vaccination for HC Workers
  • Optimize Medication Workspaces
  • Standardize Labeling/Packaging/Medication Storage
  • Identify High Alert Medications
  • Dispense Unit Dose/Unit-of-Use

29
Focus on Patient Safety
  • To Err Is Human (Institute of Medicine-1999)
  • Adverse Events in 2.9-3.7 of Hospital Admissions
  • 8.8-13.6 of these events led to death
  • Over 50 are preventable
  • At least 44,000 Americans die each year as a
    result
  • 8th Leading Cause of Death (gt MVA, Breast Cancer
    or AIDS)
  • Medication Errors Alone - in or out of the
    hospital account for over 7,000 deaths/year

30
Medication Errors
  • 2/100 admissions to academic medical center
    result in a preventable ADE
  • Each ADE increases costs by 4,700.
  • In a 700 bed hospital 2,800,000/year

31
The Origin of ErrorsPreventable Adverse Drug
Events
Source Bates, et al. JAMA (1995)
32
Preventing Prescribing Errors
33
Ownership of Medication Use Process
  • Traditional focus on prescribing errors
  • Medication errors can occur throughout the
    medication use process


34
Preventing Medication Administration Errors
Notified nurses of incorrectly addressographed
orders
Avoided medication administration to wrong pts
Orders for wrong pts identified for 11 pts

35
Ownership of Medication Use Process
Selection Procurement
Storage
Ordering Transcribing
  • Drug Shortages
  • Benadryl multidose vial
  • Wrong concentration sent
  • KCl 40meq/15 cc received

Morphine Hydromorphone Look alike/Sound alike
  • Imipenem ordered in patient
    with penicillin allergy
  • Wrong drug entered into computer using
    mneumonics

Preparing Dispensing
Administering
Monitoring
Drug placed in wrong place in automated cabinet
Heparin rate incorrect
Enoxaparin (low molecular weight heparin) ordered
in patient with low platelet count
36
Regulatory Requirements
  • JCAHO
  • National Patient Safety Goals
  • Dangerous Abbreviations
  • Look Alike Drugs
  • High Alert Drugs
  • Medication Reconciliation
  • Fall Prevention
  • Medication Management Standards
  • Pharmacist review of all orders prior to
    administration
  • Pharmacy preparation of all IV solutions
  • Evaluation of medication use system for risk
    points
  • USP 797

37
Pharmacist review of all orders prior to
administration
  • ED
  • PACU
  • All areas where a physician does not directly
    supervise medication administration unless its
    an emergency

38
Automation/Technology
  • Automated cabinets
  • CPOE
  • Bar Coding and Point of Care Administration
  • Smart Pumps

39
Automation/Technology
  • 2003 MEDMARX
  • 20 of medication errors due to computerization
    or automation
  • 27,711 reports received
  • Computer entry errors were 4th leading cause of
    error-incorrect or incomplete information entered
  • Wrong patient
  • Wrong drug
  • CPOE was 12th cause-just added to MEDMARX in May
    2003
  • Handwriting was 15th cause
  • 70 of 8000 errors involved automated medication
    cabinets due to wrong dose or wrong drug

40
Impact of Emerging Technologies on Medication
Errors Adverse Events1
  • Evaluation of peer-reviewed publications
  • CPOE, bar coding, automated dispensing machines,
    clinical pharmacy information systems
  • Conclusion Paucity of controlled, generalizable
    studies confirming the benefits of technologies
    intended to reduce medication errors and ADEs.
  • CPOE is not yet the panacea
  • 3 studies evaluated med errors and ADEs
  • All studies evaluated were with home grown
    systems therefore, transferability to other
    organizations has not been well studied
  • CPOE alerts overridden by MD 50 of the time
  • 2004 study of allergy alerts 80 overridden2
  • Recent JAMA Study CPOE system facilitated 22
    types of medication errors3

1. OrenShaffer Guglielmo. Am J Health-Syst
Pharm 2003 601447-58. 2. Hsieh KupermanJaggi,
et al. JAMIA Aug 2004. 3. Koppel Metlay , et
al JAMA. 20052931197-1203
41
Side Effects of Technology1
  • When electronic systems replace paper-based
    systems, a side effect is degradation of
    coordination as a result of privatizing
    information that was previously publicly
    accessible.
  • Patterson E S, et al. Improving Patient Safety by
    Identifying Side Effects from Introducing Bar
    Coding in Medication Administration. J Am Med
    Inform Assoc. 2002 540-553.

42
CautionBack to the Past?
  • CPOE systems may result in pharmacist review of
    only medication orders without review of all
    patient orders
  • Pharmaceutical Pharmacy
  • Care Care

43
Big Picture Thinking
Pharmaceutical Supply Chain Integrity
Regulatory Requirements
Automation/Technology CPOE Barcoding Smart Pumps
Medicare Modernization Act
Quality Mandates
Trendbending
Increasing Heatlhcare and Drug Costs
Patient and Medication Safety
Manpower Shortages
Chronic Disease Management
Pharmaceutical Industry
44
2. Exploiting Change
  • Evaluate trends and determine opportunities
  • Rapid pace of change requires being nimble
  • Dont wait for an opportunity
  • Start by planting seeds to create one
  • New JCAHO requirements support need for
    pharmacist in the Emergency Department
  • Pharmacists can ensure fulfillment of Quality
    Mandates
  • Detailed plans fail because circumstances changes
    (analysis/paralysis)

45
Risk Taking
  • Value of Experimentation
  • Lets try a little stuff and keep what works
  • 3M and Post it Notes
  • Let products and services evolve based on needs
    of the marketplace (patients/healthcare
    providers)
  • Pilot new pharmacy services
  • ED pharmacy resident or student rotation
  • 4. Creating expectations

46
5. Building Relationships
  • Create credibility
  • Understand context (Big Picture)
  • Develop content expertise
  • Develop people expertise
  • Pharmacy is a team sport
  • Technicians
  • Physicians
  • Nurses
  • Administrators

47
Possibilities in Todays Environment
  • Disease management
  • Emergency department pharmacy services
  • Post discharge follow up/case management of high
    risk populations
  • Clinical informatics
  • Medication safety specialist
  • Immunology specialist/Gene therapy specialist
  • Reimbursement specialist
  • Clinical specialist in oncology, peds, critical
    care, geriatrics

48

Priorities and Possibilities Will Change Over Time
Professional Goals
Having a purposeful life
Working in a progressive, clinical practice
environment
Demonstrating value by improving patient care
Balance/Peace Mind, Body, Spirit
Possibilities
Teaching
Building a family
Recognition for contributions
Loving/Caring Relationships
Personal Goals
49

Work
Life
  • What are Your Possibilities?
  • Determine what makes you happy
  • Be committed
  • Be passionate
  • One person with passion is better than 40 people
    who are merely interested.
  • Abigail Adams


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