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) at Dakota Regional Medical Center (DRMC) 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 DKMC 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 at DKMC, 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:
- US Department of the Inferior Indian Affairds. https://www.bia.gov/faqs/what-federal-indian-reservation. Last Accessed: February 1, 2025.
