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.