Preamble:

This article is a reflection and insight into pharmacy leadership and management on the reservation as a real-life case study. It is the third of a series of articles. Fictitious names are used to preserve and respect the identity of the facility, and the people involved.

In this article, the focus is on challenges faced once on site and expecting the unexpected, most likely atypical in a major health system or in major cities with resources. This series’ fourth and final article will focus on strategies to address these challenges and their outcomes. However, the experiences and lessons learned can be applied to challenges no matter where in the country you are.

Below are some major challenges presented to the Director of Pharmacy once onsite, but not an exhaustive list.

• The mini health system differs from the outside world: On a huge sandy block of land under extreme heat and cold due to 6000 feet of elevation, one side is the acute care hospital (~100 beds), the other side is a huge outpatient pharmacy (more volume than inpatient), one mobile trailer office is the ambulatory infusion center, another side was administration and multiple leadership offices whilst the rest of the land constitute other non-pharmacy services and clinics. Everything needed was there, however. The organization also had multiple other pharmacies about 2 hours away; one serves a small city, so the patient population, though native, is slightly different; another is in the middle of dirt roads serving both outpatient and the main mail orders pharmacy. Though a small community, the challenge was establishing a new home infusion program from the ground up as well as building another clinic and pharmacy about 1 hour away.
• Inconsistency of pharmacist skills, experiences and knowledge: Contract pharmacists were from all over the country with licenses from various states where state pharmacy law can vary. Training was the best way to ensure they were consistent with the reservation’s policies and procedures, following Drug Enforcement Guidelines and The Joint Commission Standards, Indian Health Service recommendations, etc. However, training was limited due to immediate staffing needs and their short contracts, 3 months at a time. They are expected to hit the ground running, but usually this is not the case.
• Accountability: It is challenging to hold staff contractors accountable; if you terminate their contract, you have no staff immediately, so coaching and mentoring had to be developed in their frontline supervisors and ensure staff are given a fair chance regardless of permanent contract. In fact, holding permanent staff accountable was also challenging because pharmacy leadership would have to find immediate replacements, and it was challenging to recruit permanent staff given the situation described in article one of the series. It’s a vicious cycle. It is also challenging to hold staff accountable when each pharmacy on or offsite is unique. One size may not fit all at times. Nevertheless, accountability was still enforced.
• Network infrastructure challenges: The signal was adequate on campus, but any work done after hours at home was challenged due to the internet signal. To get adequate signal, most people need to opt for satellite which is expensive. When the health-system network was down (one time it was down for several days — no internet at all), the downtime policy and incident command center had to be executed for days before we could get the appropriate help to address being isolated.

• Lack of inpatient metrics and standard industry pharmacy programs: The primary focus was on outpatient metrics where most of the revenue was actualized. There is a need to develop clinical metrics by enforcing clinical interventions and documentation. The tool was there, however nobody was expected to or held accountable to use it. Other metrics and programs that needed to be developed were inpatient productivity, diversion monitoring, metrics and investigations, opioid stewardship, drug scanning compliance, clinical interventions by pharmacy, antimicrobial stewardship, clinical cost-saving initiatives, and a revamp of the medication error process improvements by introducing a just culture.
• Recruitment and staffing challenges leading to burnout of the pharmacy leadership team. Staffing continues to be an evolving challenge where leaders must assist due to contractor callouts and delays in flights from their trips home, which reduced resources from process improvements, accountability, and new service line implementation. Ultimately, this led to burnout and resentment quickly at times from frontline managers and supervisors.
• Restructuring and re-organizing: This was much needed to be in line with the industry. For the entire system, there was a Clinical Coordinator, which should be a Manager, but recruitment was nearly impossible. Other staff had to fill in, which led to job dissatisfaction and burnout due to excessive demands on top of the daily almost 2 hours one way travel. The need for an IV Compounding Supervisor due to the changes in Sterile Compounding chapter USP <797> recent updates was clear, but no further employee was given to the department. Some roles were unnecessary and not in alignment with common industry practice.
• Inspiring, motivating, and engaging staff: This was an ongoing challenge, especially when nearly half of the department is staffed with contractors, and you have to restart with new contractors who are there for short terms and are more financially incentivized. It’s an ongoing effort daily requiring positive energy and resilience. Even when you have your own personal challenges, they need to be left at home, and you must stay strong for your staff.
• “We’ve always done it this way” mentally: Resistance to change due to lack of accountability is probably common at  other facilities. However, because there’s no state Board of Pharmacy regulations enforced at the facility, it becomes even more challenging.
• Software challenges: Electronic Health Record systems and Outpatient Pharmacy Systems did not talk properly, which can lead to errors or phone calls/faxes to resolve, creating lag time and inefficiency.

Nevertheless, there were still some strengths of the organization including but not limited to:

• Sometimes we have access faster than the outside world to drugs, especially during shortages.
• Pharmacist transitions of care, such as medication to bed and pharmacy ambulatory clinics run by pharmacists, did exist and improved the quality of care as well as reduced the workload on other healthcare providers.
• Different pharmacists from all over the country brought a variety of experiences; getting them engaged and working together is a challenge but enjoyable at the same time. They often came up with great ideas they’ve seen, which were implemented at the reservation.
• Rebuilding, restricting, and establishing new standards is rewarding after you measure the outcomes over time.
• Rarely in the outside world is a pharmacist trained or has specialties in inpatient, outpatient, and ambulatory care. By choice or fault, permanent pharmacists on the reservation had skills across all these areas.

In my self-reflection, regardless of acknowledgment or not, the impact and positive outcomes of the changes I've made during my tenure there kept me going during tough times, and setting the place for success is a strength the organization now has.

To conclude this article on a positive note, the above challenges were all addressed and will be discussed in the next and final article. 

Preamble:

This article is a reflection and insight into pharmacy leadership and management on the reservation as a real-life case study. It is the second of a series of articles. Fictitious names are used to preserve and respect the identity of the facility, and the people involved.

In this article, the focus is on preparing to get on-site, what skills and qualities are needed, and also the fit to take on the challenges of change management. This also applies to change management in any pharmacy setting, and can be a good tool for leaders who may share my philosophy “to make the world a better place” anywhere. It can also apply to rural and critical access hospitals where help is most needed.

The Checklist for the Challenge: Not your typical leadership lesson article

1. Understand what you’re getting into.
   • The time commitment can fluctuate as it’s a salaried position, but sometimes you may miss your flight home to see family and end up sleeping at the airport, which is associated with a physical toll. Sometimes, you may cancel a trip home to see family due to a “fire” at the facility which requires your leadership. I would have to drive 3.5 hours to the airport, catch the plane that’s usually delayed back to my home airport, and take another hour Uber or Lyft ride home to finally see my family after several weeks.
   • The physical environment and climate: may not be ideal, and your body has to adjust to a much higher atmosphere up to 6000+ feet elevation or extreme temperatures which can bring along illnesses or exacerbate chronic illnesses.
   • Mental health is probably the most challenging aspect in the first few months on site, moving from a big city to a town of 10,000 people with one grocery store, a few gas stations, and fast-food restaurants. Cooking will be at home after a long day as there’s nowhere to really eat out but at least it’s healthy. Also, adjusting to a different population where cultural competency and compassion are skills and traits you need to be equipped with already. One needs to possess the curiosity to learn and appreciate other cultures and be flexible and adaptable to new and unexpected circumstances while staying neutral at times from judgments as the focus is on the patient.
     
     Coming from a minority background, though raised in Australia, humility and a sense of gratitude is a must, passed down by my mother to help me succeed in this engagement. Adapting to isolation and, nowhere to go, nothing to do after hours is brutal at first. However, if you are on a mission, a reminder of the focus on the mission can help overcome isolation. Also, it’s a good time to take on further board certifications, as study time will keep you motivated. It is almost like a year in Sabbatical. Be upfront and clear with your family. Seek their support as they must share a similar philosophy or support you in your venture, knowing there’s an end.
     
     One key to success is maintaining your sanity and physical and mental health to demonstrate strong leadership characteristics as your staff mirrors your traits and emotions on any particular day.

2. Resilience: This trait is much needed in all aspects of being a leader on the reservation and as a leader engaged in change management overall. Some examples include:

   • While your goal is to educate the facility with more focus on pharmacy best practices and industry standards, the argument that will be made against you is “we don’t have to comply by that because we’re not regulated by the State Board of Pharmacy or certain bodies. It is important here to determination and have good negotiation strategies, tact, and a non-defensive compassionate mindset in presenting industry data and resources such as from the American Society of Health-Systems Pharmacist and your personal experiences to persuade every level up to and including the Chief Executive Officer and the Board. I had several opportunities to successfully convince the executive team and the Board while representing the Chief Operating Officer, as this person isn’t clinical nor has an in-depth knowledge of Pharmacy. The lesson is that you must prove yourself at first to be credible. Once they know you care and are subject matter experts in Pharmacy, they will listen.
   • Persistence is needed in not giving up when something fails the first or second time. This ranges from getting approval from all stakeholders and senior leaders to building out a much-needed home infusion program from the ground up without knowing all the answers at first, strategies to train your staff to encourage your native patients to keep their follow-up appointments in the pharmacy ambulatory clinic and being adherent with their medication regimens. A lot of readmissions are due to recurring problems and inability to get to their PCP, missing appointments, using the ER as urgent are. This could be a common problem among low socio-economic communities and minority communities anywhere in the country. Not only must you stay strong as a leader, but you must possess the ability to inspire your team to share the same philosophy as they are front line pharmacists and technicians who deal with patients face to face daily.

    

3. Patience, determination, and persistence to help people change from their deep-rooted ways: change management takes time and doesn’t happen overnight. It can be tough anywhere among your staff when you institute organizational changes, encourage patients to believe in Western medicine, or become more adherent. When results are not achieved with intense pushbacks, you can be very frustrated and start doubting yourself when it feels like everyone is against you. This is all normal, as human nature is to fear and resist change. I learned to trust my instincts more and more over the years, and they only fail when I don’t trust them. Count the small wins, wake up tomorrow, and find a refreshed new day to give it another attempt. 
   • Experiment with different strategies.
   • Listen in order to understand before seeking to be understood.
   • Find your allies who share common philosophies to change the world as more hands clap louder than one.
   • Start at the top to get support from your executive leaders.
   • Lead by example.
   • Ensure your direct reports (also leaders) share common values to cascade the change down the chain, communicate clearly while sharing the risks vs benefits and seek stakeholder investments at every level where possible.
   • Use clinical evidence in some instances and compromise at times when you may lose the battle but focus on winning the war.
     
     Over time, the ice will melt. I will share more examples of applying each of these in upcoming articles.

4. Priorities of the facility over your own at times: Plenty of articles discuss setting boundaries as a leader to avoid burnout, which isn’t wrong, but they are too general. I had a time limit set for my engagement and wanted to set a legacy after I left the facility. Thus, long hours, remote work, isolation, being away from family for long periods, including my two-year-old son, and being on call at odd night hours didn’t bother me as I had a bigger picture in mind. There is no gain without pain, and I wanted to set an example for my two-year-old son at the time that humanity comes before your own individual needs. The joy of putting your own needs first may not last long while the benefit you bring through the sacrifices can last a lifetime for some people.

In conclusion, this is not an exhaustive list, but some of the key highlights of being a change leader in any challenging setting beyond the reservation. Leadership and management are demanding and tough in themselves already, but change management is at a different level altogether. It is not recommended for new leaders as burnout can happen quickly, frustrations can skyrocket within the first few weeks on the job, mental health issues can soon set in, and one can become unmotivated and stop caring. However, it is a great position to be in as it’s a gift to lead, inspire, influence, be a role model, and leave a lifetime legacy for others to continue the path. 

The above-mentioned traits of a strong leader can be learned over time, but must be executed with commitment. Humility, life experience, and self-reflection can aid the continuous learning journey. A book or degree can help, but practice is the key to excellence. 

On an end note, my own experience and my mother’s upbringing gave me the strength to take on this challenge and be the person I am today. I am nowhere near perfect and still on my ever-lasting journey. This article in the series is dedicated to my mother, who taught me to give back to the world for all that I have and to do what I must to achieve that goal. Be on the lookout for my next article describing the start of my journey.

Preamble: 

This article is a reflection and insight into pharmacy leadership and management on the reservation as a real-life case study. It is the first of a series of articles. Fictitious names are used to preserve and respect the identity of the facility, and the people involved.

An Introduction: What is an Indian Reservation?

Unless you study history or are an avid reader, not many know what a federal Indian Reservation is. It is “an area of land reserved for a tribe or tribes under treaty or other agreement with the United States”¹. In plain English, it is like a sovereign nation with its own court and justice system for the native Indians. There are certain rules around who can own land, but ultimately, you must have some tie to native Indians by descendent or marriage. It is imperative to understand this background information to appreciate healthcare workers who work there but are not natives, as well as the challenges with leading and operating a healthcare system there.

I am a firm believer in making the world a better place and go where help is most needed – especially when most people don’t want to go, and patients need pharmacists the most. Thus, I chose to spend a year as a Director of Pharmacy (the equivalent of Chief Pharmacy Officer in the outside world) working on a reservation leading a team of 100+ pharmacy personnel (pharmacists, pharmacy technicians, pharmacy leaders) at one of the biggest reservations in the US with a population of barely 10,000 people.

Why Would Anyone Want to Work There?

The beauty of leading such a team is that you can live the Oath of a Pharmacist and make a real difference immediately to people who need you most. Furthermore, the natives are so welcoming, genuine, and sweet in inviting you into their culture and community. It is like a totally different state within the state because they know even outsiders are coming to help them. Their setup is like a mini-health system where everything is in one location including a small trauma 3 full-service hospital of 100 beds; an outpatient pharmacy with 3 other satellite outpatient pharmacies within the network; an ambulatory infusion center; and ambulatory care clinics where patients are seen by pharmacists similarly to a nurse practitioner but within their scope of practice.

The health system does not have to abide by state law, only federal law such as the Drug Enforcement Agency Regulation, the US Food & Drug Administration, and Pharmacists with a license in any state can practice on the reservation. The health system is accredited by the Joint Commission and receives funding from the government, therefore some rules and regulations could be very different than a traditional hospital. Bear in mind, this is one of the few major native health systems as most hospitals on the reservation are small, around 40 beds, and not easy to access.

The beauty of serving such a population is learning to be culturally competent, and the focus is more on patient care than metrics or profit. When you see a smile on a patient’s face, or experience the appreciation they show for things that others may take for granted in a US city, it melts your heart.

When there are drug shortages, and especially during COVID-19, the facility gets the supply of drug before other general facilities do. This is in line with what we were trained to be and sworn by the Oath of a Pharmacist:

I will consider the welfare of humanity and relief of suffering my primary concerns.

I will promote inclusion, embrace diversity, and advocate for justice to advance health equity.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for all patients.

Introduction to Challenges Leading a Pharmacy Team on the Reservation

One of the biggest challenges is getting skilled pharmacists and technicians to staff the pharmacy. Retention is a major issue. Technicians can be developed in-house with tech training programs, but there is no Doctor of Pharmacy program within hours of the facility. Speaking of which, there was always plenty to do left or right to make improvements. I was able to improve the technician training program, coached the trainer to become a better teacher, spoke at multiple cohorts’ graduation inspiring graduates, and upholding the Oath of a Pharmacist to build the next generation in pharmacy. For an everyday person it may be a small step to becoming a pharmacy technician; for a native it can be a huge family achievement. For some families, it is the first family member among multiple generations with education where the whole family comes to celebrate their graduation.

Because the area is so rural with a tiny population, it is very challenging to recruit pharmacy talent. Thus, the facility spends a plethora of funding on contract pharmacists and leadership who often get burnt out due to isolation, housing issues, being away from family, lack of growth opportunities, and no social activities after work. If pharmacists are allowed to live locally onsite, they had to pay a small amount of rent and share a room with another pharmacist. This would be tough for an educated, well-compensated professional who dedicated many years in school to become a pharmacist. Most people would not accept this role. For those that do, many – due to a multitude of reasons – end up leaving within a few months. The closest town of 80,000 people is about 1.5 hours away where permanent staff can rent or buy a house. People who work at the facility permanently had to drive this distance to and from work daily, which makes retention challenging due to burn out after long 10+ hour days especially in leadership roles. A rotating door of staff means instability, decreases quality of care, and is tough to hold staff accountable – especially when it comes to performance issues such as medication errors, consistency of care, and pharmaceutical knowledge among pharmacists coming from all over the country on contract. There are Indian Health Services officers working at the facility, but the demand intensely outweighs the need, and most pharmacy staff are not commissioned officers.

Lessons Learned and Differences Made

Despite many challenges during my tenure on the reservation, I was able to improve staff morale and engagement; set a higher standard of accountability; bring process improvements to workflow; develop new policies and procedures; develop new positions including job descriptions; restructure the department; improve medication safety; and introduce a just culture using lean methodology. I also improved outpatient pharmacy customer service and overall pharmacy operations to be aligned with current industry standard of practice as well as training, coaching, and mentoring rising stars to become leaders before I leave. I also led the building out of a new satellite pharmacy and long-term care facility.

How did I do this? Be on the lookout for the next chapter of this article for strategies in change management in this unique situation which can be applied to any in or outpatient pharmacy across the USA.

How do I know I made a difference or was effective? I bumped into my former staff at a national conference one year later and received reports of positive impacts I had left behind.

Overall, I had a major impact on the facility in many aspects, and I look forward to sharing learning lessons in the next article.

_References:

1. _{U.S. Department of the Interior.} https://www.bia.gov/faqs/what-federal-indian-reservation_{. Last Accessed: February 1, 2025.}

[Original publication date 7/5/2024] Diversion management starts before a new staff member walks in the door. It is looking for red flags, even before any access to medications is given. It starts before any staff is hired and can be before an interview is offered. Most hiring managers assume that the human resources team is doing their due diligence to monitor for potential issues that may arise, but without asking questions and knowing the process, it is possible that expectations do not meet reality. In addition, we assume that licensing boards are also watching for possible risk factors, but many of us have not reviewed the business and professions code related to licensing and possible loss of license, which may not factor in every misdemeanor charge.

To start from the beginning means that the pharmacy diversion lead needs to meet with human resources to define a set guideline for onboarding any new employee. This information should be shared with your diversion committee or group, and guidelines should be created for screening new hires. This includes “deal breakers,” for example a Driving Under the Influence (DUI) or other charge related to alcohol, illegal, or dangerous drugs within the last 3 years, regardless of felony or misdemeanor status.

This may also mean training human resources staff on how to properly review a professional license, including any public documents and the charges to the applicant by the board. Knowing the issue and the timeline of events better allows the hiring manager to make an educated decision on hiring, and/or can allow the diversion team to better monitor those at a higher risk. For example, a recent hire had public documents about past diversion and substance abuse treatment at a prior facility. This was not discovered until possible diversion occurred at the current facility. The knowledge of the past diversion would have helped decrease the risk to the new institution, the staff member, and most importantly the patients he was treating.

If the decision is made to hire a licensed staff member, prior to giving them access to automated dispensing machine (ADM), the system access request should require the staff member to acknowledge their risk of diversion. This includes asking questions regarding past infractions, but also asking about any current or pending investigations at previous facilities and/or within other localities or states. It is also important to identify the system access request form as a legal document, so that should a new staff member choose to put inaccurate information on the form, termination can be considered.

The system access request form allows the diversion team and the pharmacy informatics team to capture individuals at high risk who may have not been identified by human resources. For example, an employee may have been hired but while waiting to be onboarded was arrested for a DUI, or an employee recently left an institution after being placed under investigation for diversion but with a licensing board that is only starting the investigation process.

In summary, diversion management is not just what is occurring within the walls of the institution. It starts when a person applies to your facility. It is critical to research all avenues for areas of concern, and to ask important questions and understand the current licensing and onboarding process. It is every member of the team’s responsibility to ensure that the staff, facility, and patients are at the lowest risk possible.

The healthcare industry is undergoing rapid change, placing pharmacy operations at a critical juncture. As drug prices rise and reimbursement rates fluctuate, health systems are increasingly seeing the untapped potential of retail pharmacy services as a key tool for generating revenue and improving patient care. This shift calls for innovative strategies to maximize revenue in pharmacy settings while maintaining a careful balance between financial sustainability and high-quality patient care.

In recent years, the role of pharmacies within health systems has seen significant change. No longer viewed simply as a cost center, pharmacies are now recognized as potential profit drivers and essential parts of integrated care delivery networks. This shift, highlighted by a recent Premier survey of health system leaders, is not just about financial gains. It reflects a broader approach that addresses financial challenges while also supporting population health efforts and improving patient outcomes.

One of the most promising opportunities for increasing revenue is reducing hospital readmissions. With the annual cost of 30-day readmissions reaching $41.3 billion, or $13,800 per Medicare patient, the financial impact is considerable. Onsite retail pharmacies are in a strong position to address this issue by providing thorough medication counseling before discharge, which significantly reduces the chances of readmissions and emergency department visits.

The advantages of onsite retail pharmacies extend far beyond readmission reduction. Research indicates that nearly 30% of patients fail to fill their initial prescriptions within a week of discharge. The mere presence of an onsite pharmacy serves as a powerful visual catalyst, markedly increasing the probability of prescription fulfillment. It has been proven time and time again across the United States that pharmacists embedded within healthcare systems can offer immediate interventions that their external counterparts often cannot, recommending cost-effective alternatives, facilitating connections with financial assistance programs, and collaborating directly with inpatient care teams to address potentially hazardous prescriptions, thereby enhancing patient safety and care quality.

For eligible hospitals, the 340B Drug Pricing Program represents a significant avenue for revenue enhancement, with participating retail contract pharmacies reporting returns on investment as high as 15%. However, capitalizing on this opportunity demands meticulous record-keeping, regular price file updates, robust tracking systems, and a comprehensive understanding of the regulatory landscape.

Efficient inventory management emerges as another crucial factor in revenue maximization. The implementation of advanced inventory systems, coupled with data analytics for demand prediction and strategic negotiations with wholesalers, can substantially reduce costs and enhance cash flow. Regular evaluations of slow-moving items and consideration of alternative sourcing further optimize inventory operations.

Diversification of revenue streams through expanded clinical services offers yet another avenue for growth. Comprehensive medication therapy management programs, immunization services, and specialty pharmacy offerings for high-cost medications can significantly augment revenue while simultaneously improving patient care.

To truly flourish in this evolving landscape, health systems must think beyond their current operational paradigms. This may involve geographic expansion to high-traffic locations, forging partnerships with local employers to access new patient populations, or implementing mail-order services to enhance convenience, foster customer loyalty, and meeting the consumer where they are at by getting with the times of technology and delivery.

As many organizations continue to scale for success, it is imperative to understand that maximizing revenue capture in pharmacy operations demands a nuanced and multifaceted approach that harmoniously balances strategic expansion, operational efficiency, and an unwavering commitment to patient care. By conceptualizing their retail pharmacies as strategic assets capable of enhancing care delivery, mitigating readmissions, and generating substantial revenue, health systems can position themselves advantageously in the increasingly complex healthcare ecosystem.

As we navigate this transformative era, those who can adeptly maneuver through these intricacies and embrace this comprehensive approach will not only ensure the financial sustainability of their pharmacy operations but will also play a pivotal role in shaping the future trajectory of healthcare delivery. The pharmacy of tomorrow transcends its traditional role as a mere dispensary, emerging as a key player in the dual pursuit of superior health outcomes and financial stability for health systems nationwide.

References: Tarr, L. D., & Lupica, S. (2004). Workers\u27 Compensation. https://core.ac.uk/download/232791407.pdf

I strongly believe that every medical center needs a dedicated medication safety leader. The American Society for Health-System Pharmacy (ASHP) published a position statement on the Role of the Medication Safety Leader that I highly encourage all pharmacy directors to read. Medication safety simply cannot be another hat one wears as a pharmacy manager or director who is also managing budgets, monitoring financial performance, implementing cost-saving measures, addressing regulatory concerns, maintaining a competent and engaged staff, and more! A medication safety leader sets the medication safety vision, identifies opportunities to improve the medication-use process, and leads efforts and initiatives to prevent medication errors. For those who have bought into this idea and secured the funding to hire a dedicated medication safety leader, wonderful and congratulations!  Here are some tips on what to look for in your future medication safety leader along with how to assess for these traits during the interview.  The same ASHP position statement referenced above lists 19 characteristics that medication safety leader should have which I agree with 100%.  I am going to add (or highlight) five (5) more.

1. Assertive, but not aggressive. “Appropriate assertiveness” is already listed as a desirable characteristic on the position statement (characteristic #15), but I want to call out the need for the appropriate assertiveness and why to avoid aggressiveness. Medication safety leaders are often put into the position of having to convince various levels of leadership of something- to heed the lessons of medication errors, to consider a new process, to implement safety technology, etc. Many of which are unpopular ideas from the start for a variety of reasons: cost, level of effort to implement, increased workload, or even normalcy bias (the concept that an outside error won’t happen here).  Appropriate assertiveness refers to advocating for safety to the right stakeholders, at the right forum, and at right time.  Being aggressive does not help to convince leadership. Instead, it turns them away.  During an interview, ask candidates about how they manage conflict or how they respond to criticism and look for non-verbal cues such as eye-contact and tone to assess for assertiveness.
2. Highly organized. At any given moment, medication safety leaders are juggling a multitude of projects and initiatives at various stages – some in flight, some they are still advocating or getting buy-in for, some nearing completion or in the monitoring phase. This is in addition to day-to-day medication error review, presentations, and meetings. It takes a highly organized individual to keep everything straight and moving forward. During the interview, ask candidates how they stay (or plan to stay) organized with multiple projects or ask them to walk you through how they managed a complex project.
3. Flexible. In my nine years in medication safety, I have come to realize the need to pivot multiple times with medication safety projects. At times we need to pivot within the project itself i.e. we were headed north, but now realize we need to head northeast (metaphorically speaking). In addition, we often need to pivot our attention, efforts, and energy from one project to another because of organizational priorities or momentum (sometimes when a new error happens it increases interest and speeds up a safety project).  During the interview, some of the same questions for assessing the ‘highly organized’ trait may be used to assess the candidate’s level of flexibility. You can also ask how they adjust to changes that they have no control over.
4. Collaborative. Nothing in medication safety can be done in a silo. A medication safety leader cannot develop a safer workflow without engaging front line workers and operational leaders.  In addition, more often than not, medication safety projects will be multidisciplinary in nature- involving any combination of physicians, nurses, respiratory therapy, central supply, bioengineering, pharmacy, healthcare risk, and others. During the interview, ask candidates to explain how they collaborated with others on a project.
5. Curious. Being curious helps to do so many things- develop rapport, learn about a workflow or system, think outside the box, draw connections, and so much more.  During the interview, ask candidates to tell you about a time where they had to complete a project but were not given all of the details. Look for how many questions they ask during the interview about the position and the organization as well as the quality of those questions. Routine questions asked by many candidates may not be reflective of natural curiosity, but thoughtful questions that perhaps reference something discussed earlier might point to a naturally curious individual!

What is psychological safety? Psychological safety is a shared belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. In a psychologically safe environment, people feel comfortable in asking a question, raising a concern, providing feedback, and contributing to a discussion without fear of negative consequences.

Why have a psychologically safe environment? There are many benefits to creating a psychologically safe environment in a pharmacy including increased workforce engagement and motivation, increased safety culture, and decreased patient harm. Interestingly enough, psychological safety is embraced by other industries such as the technology industry for its ability to drive innovation.

How can I create a psychologically safe environment in my pharmacy?

1. Share errors. Start daily huddles and team meetings with a safety story. Keep things simple, short, and sweet. Rotate who shares each day. Recognize and reward people for speaking up and sharing errors and close calls. This is also great opportunity to share what has been done to address past errors. As a leader, practice active listening as things shared could be future process improvement projects!
2. Thank people for sharing their opinions – even when you may disagree! In a psychological safety training exercise I attended, we were asked to discuss as a group what it would "feel" like in a psychologically safe environment of which we thought everything would be rosy with hearts and rainbows. Our instructor shared that psychological safety can feel uncomfortable. We were all dumbfounded. The instructor went on to explain that as a leader, you may not be used to someone disagreeing with you which will feel uncomfortable. Fight the urge to defend your position and just remember that everyone brings a unique perspective.
3. Model vulnerability. As leaders, we feel like we should have all the answers, fix all the problems, and be absolutely perfect all the time. Leaders are humans too. There is no shame in asking for help which may take the form of delegation, collaboration, or even having motivated team members take on a stretch project. Additionally, admitting to the team your mistakes and shortcomings shows vulnerability, builds trust, and sends a message that everyone makes mistakes but we can all learn from it.

One of the greatest and ongoing conveniences that offers constant progress certainly lies in technological advances. We see this in every aspect of our daily lives. For evidence of the massive societal shift that technology offers look no further than your cell phone, tablet, or computer. It’s a safe bet that once you think you have it down, the next shiny toy hits the market.

Healthcare, particularly Pharmacy, is not immune to these phenomena. The rapid advancement in all areas of Pharmacy practice aided with well positioned technology has presented an array of opportunities to assist a well-oiled Pharmacy program to elevate to the next level. With that comes the responsibility to utilize the appropriate technology based on the individual needs of the practice environment and to go all in. Think of that treadmill you had to have on January 2^nd, to embark on your New Year’s resolution. You either have your ticket to your beach body or a $2000 hanger. It’s all up to you how you employ your shiny new toy.

Let’s look at a few topline thoughts on technology and the how/why you would want it, how you would use it and what may be worth it or not based on your strategic focus.

The first thing to evaluate is your clinical programming and the human involvement you want to incorporate. For this you must evaluate several key points, such as how you want your technicians and pharmacists to matriculate outside the pharmacy. For example, if you want pharmacists rounding more, perhaps have them decentralized permanently, or have technicians circulating on the floors and in the ED say for medication reconciliation, then you need to have the technology to perform automated duties in the pharmacy.

Next you need to look at the cost element. Just because it looks great and has a significant price tag doesn’t mean you need it. Look at the contracts you have to see where you can make deals or lean into a barter type relationship. Maybe if you offer to be a Beta site for new technology, you can get a much better deal if you are willing to share outcomes. Maybe you haven’t made the most of economies of scale and you have some opportunities there.

The next big question is your regulatory readiness and how well you have performed in recent surveys. If you find you are running a fire drill every time you have to produce data on survey, then the technology you need is more along the lines of automated reporting and/or catching issues in real time. For example, if you have automated medication dispensing cabinetry and need to produce diversion information, the reports that are baked into this technology are invaluable.

In terms of technology groupings, let’s break them down into bite size pieces.

Automated Dispensing Machines. Most likely you already have this or want it. The question is do you use all or most of what this system has to offer? Do you have overlapping technology that you don’t need because you have not tapped into the full cadre of offerings your chosen system is capable of? The companies that sell this technology also offer support that is baked into the contract. Talk to them about what they suggest and schedule training and overviews a couple times a year to assure you are up to date on the software, are using the administrative options to their fullest capacity and evaluating anything new that may have been rolled out on their platform. This may seem like a no-brainer although you may be surprised at what you have been missing out on. Maximize everything in your chosen system to create diversion protocols, reduce possible adverse events and to stay ahead of the last outdated pill lurking around just begging to be found on your next survey.

Remote Verification. Let’s say you want to, need to or have no choice but to keep the FTE component down. Depending on your state laws, you likely have the ability to incorporate your ADM’s with remote verification for overnight coverage for example, thus not relegating this to the emergency cabinet that has to be reconciled the next day as well as offering real-time verification of the order to satisfy regulatory oversight. Pharmacy should not be practiced only during daylight hours.

RFID. There are so many options here and the technology is great, but not widespread and/or financially attainable which means grouping RFID into buckets. It can be used for specialty medications using technology that is like a hotel mini fridge essentially making these consignment medications. You only pay when you use them and get reminders when these wildly expensive therapies are about to go out of date. Another great grouping is code cart replenishment and documentation, two big issues for every hospital since the beginning of time. RFID technology can make refilling and checking the trays much more streamlined, allowing for the redirection of pharmacists’ time incorporating the reporting from the RFID and tech on tech checking depending on state laws.

Computerized Physicians Order Entry. Everybody must have it. Many are annoyed by it. Here’s the thing, gradually increasing the use allows for order sets to be used more effectively as well as testing the limits of policy acceptance. Let’s say that your hospital has approved TPN to be written by Clinical Nutrition, and the orders are based on pre-mixed PPN and TPN. In this scenario, physicians’ time is eased up, treatment is expedited, the expertise of Clinical Nutrition is appropriately employed, and the relevance of the program can be evaluated by the reporting that can be obtained. This is an excellent story to tell when the JC shows up in your lobby.

We have mentioned just a scant few of the possibilities available to create an optimized technology infused clinical environment. The choices available and reasoning for use could go on for many articles with one overarching theme which is when thinking about what you have, what you want and what makes sense take the whole picture into account as well as your ability to make the most of your options. To achieve this, ask yourself a few key questions. Am I using what I have to full capacity? What gaps do I need to fill in? Where are our vulnerabilities and what do we struggle with? If you work backwards from there you can engage in a more mindful fashion all around turning your attention to the technology that works for your patients and your practice. 

Leonid Gokhman, PharmD, manager of pharmacy business operations at Harris Health System, takes a proactive approach to running his operation, rather than being reactive. He encourages his pharmacy, nursing, IT and revenue cycle peers to adopt this mindset.

“If you’re reactive, you’re creating so many other issues — not only for yourself, but for multiple teams,” Dr. Gokhman says. “If you're able to put things in place that prevent issues from happening in the first place, you drastically cut down on a lot of clutter, errors and unnecessary work.”

Part of taking a proactive approach means working directly with the frontline staff not only on project development and implementation, but maintenance as well. Staying within the pharmacy walls and only working with your team means you’re not getting the bigger picture of how the hospital system operates, he says. 

Plus, when major departmental initiatives are carried out in silos, crucial components may be overlooked. This oversight could result in either beneficial or detrimental downstream effects for other departments.

Five years ago, he was asked to participate in the hospital system’s vaccine redesign project. When he first started the project, the error rate was almost 50%. (Yes, you read that right. 5-0.)

“If you have errors in your clinical documentation and on your charges, you will not get paid or get paid inappropriately,” Dr. Gokhman says. “As I was digging through the system build and working with nursing leadership — it became clear to me that the system build was way too complicated. Our providers had five different workflows, requiring them to memorize numerous charge codes to manually post administration charges and contend with confusing order names. This diverted their attention away from direct patient care.”

Five workflows were four too many. His first step was to consolidate multiple provider and nursing workflows into one. Next, vaccine order names were updated according to ISMP (Institute for Safe Medication Practices) and Epic guidelines. Finally, a system build was implemented to automatically post vaccine and vaccine administration charges based on the documentation for each vaccine.

“Keep it simple,” Dr. Gokhman says. “When frontline staff are presented with too many options, they are prone to choosing incorrectly or resorting to workarounds. These workarounds might seem beneficial, but on the frontend, they lead to order entry and documentation errors. This causes multiple coding, billing and reimbursement issues on the backend.”

By simplifying and automating the workflow, they’ve drastically cut down the number of errors.  Recently, a third-party audit revealed a 100% vaccine billing compliance rate, surpassing the industry standard of 95%.

The day before I was expecting an employee to return from maternity leave, I received her resignation letter, citing reasons of wanting to focus on motherhood. The timing was unfortunate, but I was happy for her. As a mother, this made me wonder if I was making good life choices. As a manager, this made me feel like I’m competing with little babies for mom’s time and talents. How can we retain good employees when they’re in love with the competition? The truth is, we can’t. The kids always win, and they should.  We can only hope to join mom in loving these little, squishy sugarplums by giving her the support she needs to excel at home and then in the workplace.

Raise Benefits Awareness

They say, “a baby changes everything,” and this extends to the need for benefits and the enrollment period.  Benefits could be anything from financial planning, expanding insurance coverage and assigning beneficiaries, or simply knowing they have employee assistance for stress management. Having insurance coverage for breast pumps, lactation consultants and pelvic floor physical therapy is tangible proof of the company’s support for mothers of newborns. On-site childcare is an attractive benefit, too! Encourage expecting moms (and dads) to consult human resources and benefits management about what opportunities are available through your institution.

Support the Breastfeeding Journey

Time spent breastfeeding a child can equal as much time spent working a full-time job. The American Academy of Pediatrics (AAP) recommends exclusively breastfeeding for at least six months. Compare that to maternity leave, which can be as short at 6 weeks. That means new moms are working two jobs! Before she delivers, make her aware of lactation services which can include an on-site lactation consultant, time and space to express milk, and storage space for breastmilk. The AAP is an excellent resource for this, and they issued a news release in 2022 citing recommendations for corporate support of  breastfeeding:  American Academy of Pediatrics Calls for More Support for Breastfeeding Mothers Within Updated Policy Recommendations (aap.org)

Creative Scheduling & Cross-Training

Drug shortage mitigation proved to be a mere training ground when compared to navigating the workforce shortage, making employee retention seem more important than ever before.  Overall, what moms need from their employer is to be able to leave work to care for their child without judgement from management and coworkers. The workflow should be designed so mom can meet the needs of her sick child, or attend a school function, without added guilt of her workflow left unattended. Creativity is key when it comes to meeting the needs in the department while balancing employees’ needs outside the department. This may mean schedule changes, creating PRN staffing requirements, or expanding benefits to part-time employees. Cross-training employees ensures the needs of the department are met when special occasions arise during this precious season of life.

Moms have a reputation for being pretty remarkable creatures. Research has shown that mothers’ brains are equipped to be “more efficient, flexible, and responsive” as a result of changes occurring in the perinatal period.^1,2 That makes sense when we think of our cavewomen ancestors protecting their young, but these traits make valuable employees in today’s era, too. She may not be shooing away a sabertoothed tiger, but it can feel that way as she juggles the demands of work and home life. Working with employees as they venture through seasons of life, especially young motherhood, lets them know they are supported and valued at work, and creates a space for them to build a career.

These opinions are those of the author and not of Pharmacy Angle or USA Health.

Ref:

1 Kinsley, Craig Howard, and Kelly G. Lambert. “The Maternal Brain.” Scientific American, vol. 294, no. 1, 2006, pp. 72–79. JSTOR, http://www.jstor.org/stable/26061302.

2 Orchard, E.R., Voigt, K., Chopra, S. et al. The maternal brain is more flexible and responsive at rest: effective connectivity of the parental caregiving network in postpartum mothers. Sci Rep 13, 4719 (2023). https://doi.org/10.1038/s41598-023-31696-4.