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 fourth of a series of articles. Fictitious names are used to preserve and respect the identity of the facility, and the people involved.

This article focuses on strategies to overcome challenges faced by a Director of Pharmacy on the reservation described in article three. These strategies can be executed in similar situations anywhere across the country and in any pharmacy setting.

Challenge 1: Establishing a New Service Line - Home Infusion

Strategy: 

• Continuously advocate and find solutions to roadblocks presented by the C-Suite from credible sources and draw from previous experiences. 
• Build allies with other leaders, which starts by building relationships from day one and delivering results consistently to trust as the subject matter expert, leadership and project management capabilities

Outcomes: Barriers and negative attitudes were broken down with justifications and persistent efforts. I led the project, drew out the workflow, and picked up the project where my predecessor had given up.

Challenge 2: Building a New Pharmacy

Strategy: Building a new pharmacy requires check-ins and follow-ups with the Chief Operating Officer who manages the project. Establish a relationship with the C-Suite similar to the above with other leaders. Plan and prepare ahead for regulatory body approvals, drawing on your previous experience, and assist them with the design of a new build-out and project timeline. Pharmacy usually needs to be built out early and first due to regulations and infrastructure setup. Share experiences humbly, providing references where possible.

Outcomes: Progress was made with the design, layout, and equipment required of the pharmacy during my tenure there. Education was provided on next step needs in a chronological manner with regulatory bodies prior to my departure.

Challenge 3: Inconsistency of Pharmacist Skills, Experiences, and Knowledge

Strategy: I reviewed the training gaps on both the inpatient and outpatient sides by delegating to my assistant directors inpatient and outpatient and vetting through the materials comparing to industry standards (ASHP, USP  <797, 800> standards), other references and experience. All new pharmacists were trained on both inpatient and outpatient starting with outpatient first as they build their skill sets and depends on how long they would stay with the organization. Trainers were carefully selected and paired up based on a match of style also to ensure best delivery of the materials. Regular check ins by leadership would occur to ensure they’re on track and provide feedback on support needed.

Outcomes: Consistency of performance, expectations, staff satisfaction, and morale all improved. It was also less challenging to ensure accountability since everyone is now consistent with their training.

Challenge 4: Accountability

Strategy: 

• New training was developed to assist with setting expectations at a consistent level.
• Almost daily or twice daily rounding (sometimes) by the Director of Pharmacy and check-ins on staff both professionally and personally was appreciated and improved morale – especially during the first few months of establishing rapport, trust, credibility, and support.
• Recognize staff at daily huddles, at staff meetings, and in front of senior leaders. 
• Held staff accountable by working with HR to investigate and understand different sides of the stories before disciplinary action occurs.
• Lead leaders to understand coaching and progressive disciplinary process to ensure they are accountable.
• Coach, mentor, and train leaders to adapt to their style and needs weekly and monitor their growth. Provide timely feedback as well as compliment them on their achievements and progress.
• Have weekly meetings with leaders providing a safe psychological space where staff can speak their mind.
• Develop a Just Culture and give staff grace. Not every mistake is punitive unless it is repetitive after coaching.

Outcomes:

• Improved morale and overall positive culture within the department.
• Improved perception of the department across the organization.
• Performance improved but continued monitoring is required and continues to be a challenge with leaders stepping into staffing roles due to staff shortage.

Challenge 5: Work Cultural Issue and Lacking Just Culture 

Strategy:

• Develop a Just Culture using lean Six Sigma methodology, root cause analysis, and various other tools through a multicampus-wide initiative, and results were presented to the C-Suite. The Director of Pharmacy shared the vision with the team and sought their feedback and support collaboratively as a team.
• Work with the Chief Nursing Officer and Chief Medical Officer to help them develop a Just Culture among their teams using data, an educational, collaborative, and supportive approach.

Outcomes:

• Just Culture was established, and reporting of medication errors increased by 500% at one site (pharmacy).
• The pharmacy’s reputation was rebuilt among the C-suite and Board of Directors, moving towards a non-blame culture and more collaborative process improvement culture.
• Other clinicians were held accountable by the Chief Nursing Officer and Chief Medical Officer, starting with education first before disciplinary action. The goal was nonpunitive and education-first.

Challenge 6: Network Infrastructure was Challenged

Strategy:

• Participated in a root cause analysis and presented solutions from experience at other facilities.
• The pharmacy revised the downtime plan and the tools and process improvements.

Outcomes: 

• Tools and resources within the pharmacy department were better developed. 
• Workflow was improved for future recurrence within the pharmacy department, but some issues, such as IT-related issues, were outside of the pharmacy’s scope of control.

Challenge 7: Lack of Inpatient Metrics and Standard Industry Pharmacy Programs

Strategy:

• Metrics were introduced through teamwork among the leadership team where the Director of Pharmacy would delegate, trust, and verify. Clinical metrics were developed and monitored by enforcing clinical interventions and documentation. The Director provided coaching and mentorship along the way.
• Other metrics and programs were developed and monitored, including inpatient productivity; diversion monitoring; metrics and investigations on 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.

Outcomes:

• Results were provided on monthly reports in line with industry standards.
• The C-Suite was pleased with the changes implemented and improved pharmacy services by setting a standard, reinforcing and monitoring improvements month over month.
• Pharmacy gained more respect from senior leadership due to the value we bring to safe, timely, and effective patient care backup by measured data (metrics).

Challenge 8: Recruitment and Staffing Challenges Lead to Burnout of the Pharmacy Leadership Team

Strategy:

• Contractors and agency staff were the norm for this pharmacy operation. Thus, working with multiple vendors and keeping a non-judgmental open mind, some traveler pharmacists were actually high performers once onsite and would often stay for multiple renewals of their contract. By rebuilding a positive work culture, some contractor staff converted to permanent staff which was a win-win overall.
• It is important to note that traveler pharmacists may have different approaches or be at a different stage in their career than permanent staff. When interviewing, be fair and assess the person as they are. Avoid judgements against employment gaps or new graduates as long as the candidate can adequately justify. It’s important to be compassionate and give people a chance if they have the right mentality, attitude, ethics, and morals. Skills and competency are qualities you can train.

Outcomes:

• Interviews were frequent but this is how we kept the department going. A long-term solution of permanent staff is challenging due to the rural location and housing. The Director of Pharmacy was resilient and persistent, which set the tone for the rest of the pharmacy leadership team in recruitment.
• Providing candidates with an opportunity resulted in some candidates staying onboard as permanent staff and moving up within the department over time.
• Some traveler candidates took on more responsibilities such as transitioning to help with inpatient and was able to staff both outpatient and inpatient. This is rare in the industry: a pharmacist working in both roles at one health-system.

Challenge 9: Restructuring and Reorganizing

Strategy: Some roles were not aligned with industry standards around changing regulatory needs, such as an IV Compounding Supervisor, due to the changes in Sterile Compounding chapter USP <797> within recent years. Other roles were not clearly defined so they were changed to give the department more frontline staff help. Given that there were no further full-time employees allocated in the budget, the restructuring of certain roles had to create new roles to make the organization in line with other renowned health-care systems that the Director of Pharmacy had worked at. The remaining challenge then moves to the next stage of recruitment or promotion from within, necessitating training, mentoring, and coaching.

Outcomes:

• Some staff were promoted from within, then mentored and coached, which improved their job satisfaction, especially among technicians where some felt there was no way to move up.
• Ongoing recruitment efforts and positive results for other roles occurred (refer to the recruitment and staffing section of this article).

Challenge 10: Inspiring, Motivating, and Engaging Staff

Combatting the  "We've Always Done It This Way" mentality

Strategy:

• It was essential for success upon starting the role that the Director of Pharmacy leadership shared her vision, her leadership style, and her purpose (present to help); she explained changes with the "why" behind them and sought buy-in when possible; she empowered staff to speak up and do more beyond their responsibilities; she reminded staff of the Oath of a Pharmacy, and that working as a pharmacist or a pharmacy technician is a privilege – not a right – combined with maintaining an open door policy.
• It takes a certain personality and leadership style (with traits such as being adaptable, flexible, compassionate, humble, frequently self-reflecting, transformational, empowering, personable, active listener, highly accountable) to lead a dynamic team when nearly half of your department is staffed with contractors, and you must 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 the Director of Pharmacy has her own personal challenges, they need to be left at home. One must stay strong for their staff as they will mirror you and lean on you for support.
• An emphasis on listening to staff feedback and having the patience to explain in multiple different ways that the industry is evolving and that being stagnant means falling behind, as well as being previously not cited, which doesn’t make it right or mean that citation cannot happen in the future.

Outcomes:

• Trust, respect, and support were felt by the staff quickly within the first full week. Resultantly, senior leadership and pharmacy staff, as well as others within the health system, co-operated and supported the Director of Pharmacy's subsequent projects and initiatives.
• The Director of Pharmacy was asked by many staff, leaders, and the executive leadership to stay on board permanently or at least for several years due to the overall revamp of the Department of Pharmacy in all aspects. Unfortunately, due to the location and family reasons, the Director of Pharmacy could not stay beyond her committed year, but had set up the department for success in multiple ways and still keep in touch with the organization leadership when needed, providing advice on a pro-bono basis.

Challenge 11: Pharmacy Software

Strategy: As part of the Lean Six Sigma process improvement project, new software that is more in line with regulatory requirements and improved efficiency was needed. The Director of Pharmacy led the project in vetting several current trending software applications on the outpatient side through site visits and anecdotes, meetings with vendors, and involving other subject matter experts internally to help vet out the best vendor.

Outcomes: The Director of Pharmacy had pinpointed the point of failure, set up a structure, and handed it off to the leadership team to complete the project as she had completed her committed tenure and returned home to her family and other work engagements.

Conclusion: Overall, the challenges, strategies, and outcomes of this health system mentioned in this series were not limited to just what was referenced. These were some major highlights that could be helpful to pharmacy leaders overall. 

For further information or questions, the author can be contacted via statrxllc@outlook.com. Thank you.

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.}

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About Intelliguard: Intelliguard is a leading provider of advanced RFID-enabled inventory management solutions, empowering hospital and health system pharmacies to enhance medication safety, reduce waste, and improve operational efficiency. By delivering actionable insights and streamlined processes, Intelliguard supports healthcare providers in delivering the highest standard of patient care.

BRONX, N.Y. – Ruth E. Cassidy, B.S., PharmD, MBA, FACHE, FASHP, has been named the inaugural chief pharmacy officer at Montefiore Health System. Dr. Cassidy assumed her new position today.

Dr. Cassidy brings to Montefiore decades of pharmacy practice excellence, with an eye towards medication safety, regulatory oversight and delivery of exceptional patient care. She will oversee pharmacy services across Montefiore's acute and ambulatory locations as well as Montefiore's Specialty Pharmacy, one of the most advanced specialty pharmacies in the region, providing home delivery of medications throughout the Bronx and Westchester.

"There is no better person than Dr. Cassidy to be our inaugural chief pharmacy officer and member of our leadership team dedicated to enhancing patient and caregiver care and support," said Peter P. Semczuk, DDS, MPH, Regional Senior Vice President for New York City and Executive Director, Moses Campus & Faculty Practice Group, Montefiore. "Her role will be central as we continue to invest in new technologies and quality assurance strategies that streamline medication processes, reduce burden on providers and most importantly, optimize patient outcomes."

The Rx for Addressing Care Complexity

Chronic disease exacts a significant toll on the health and well-being of New Yorkers. More than 40 percent of New York adults suffer from at least one chronic disease, making medication management vital. Dr. Cassidy will be responsible for managing pharmacy operations, spanning novel cancer breakthroughs that genetically modify a person's own immune cells to attack cancer cells, to building on successful communications strategies that support care coordination and mitigate potential drug side effects following hospital stays.

"I've been privileged to spend most of my career serving Bronx patients and families," said Dr. Cassidy. "By joining Montefiore and leading pharmacy operations, an area that touches every service, I have the opportunity to leverage existing relationships with community partners, bring forth new collaborations across the system and ensure a consistent experience across our campuses that will benefit every provider and their patients, I can't wait to dive in."

Prior to joining Montefiore, Dr. Cassidy, served as Senior Vice President of Clinical Support Services and Chief Pharmacy Officer at SBH Health System, where she designed and oversaw the system's first Outpatient Pharmacy, first Specialty Pharmacy and launched an American Society of Health-System Pharmacists-accredited pharmacy resident program.

Cassidy earned her Master of Business Administration from West Texas A&M University, her Doctor of Pharmacy degree from the University of Florida College of Medicine and her Bachelor of Science degree in Pharmacy at St. John's University.

[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.

[Original publication date 9/3/2024] - Pharmacy technicians are the backbone of successful pharmacy operations. In health system inpatient pharmacies, they handle complex tasks such as sterile compounding, inventory management, controlled substance security, automation oversight, and handling of hazardous medications. They work tirelessly behind the scenes to ensure patients receive safe and quality pharmaceutical care. The ongoing shortage of qualified pharmacy technicians is a significant barrier to progress in an evolving healthcare landscape in the era of technological revolution.

Over the past decade, almost all states have introduced licensing and national certification requirements for pharmacy technicians. Despite these new requirements, salaries and benefits for these positions have not kept pace, leading to a significant industry lag. The shortage was further exacerbated by increased burnout during the COVID-19 pandemic and a growing workload due to an aging population, stricter regulations around sterile compounding, and increasing complexity of tasks.

In health system inpatient pharmacies, the technician shortage is a major challenge, second only to drug shortages. Recruiting, onboarding, and training technicians are time-consuming processes, and staffing gaps lead to stress, lower morale, and additional vacancies. To address this issue, consider implementing competitive pay and hiring incentives, a career ladder, flexible scheduling, awareness campaigns, and robust training programs.

Competitive Pay and Hiring Incentives: Pharmacy technicians earn between $30,000 and $50,000 annually, with advanced roles reaching $50,000 to $60,000. The Bureau of Labor Statistics projects a 6% increase in job outlook for pharmacy technicians over the next year. Health system pharmacies should partner with local HR teams to conduct a thorough market pay review and implement competitive salaries and benefits to attract candidates. Additional incentives, such as sign-on bonuses and tuition reimbursements, are also effective in drawing more candidates.

Career Ladder: Offering career advancement opportunities can attract high-caliber candidates. These types of candidates are the most productive and committed members at the core of pharmacy operations. Positions like operations coordinator, lead/supervisor, chemotherapy specialist, IT specialist, and quality/regulatory compliance lead are becoming more popular and can attract committed technicians.

Flexible Scheduling: For 24/7 health system inpatient pharmacies, creating schedule flexibility can be challenging. Leaders should review workflow plans to identify opportunities for flexible shift times and adjust schedules to attract candidates who cannot commit to rigid hours. Consider shifting repetitive tasks to more popular hours, such as 8 a.m. to 5 p.m.

Awareness Campaigns: The shortage is partly due to a lack of public awareness about the career prospects for pharmacy technicians. Use social media, local job fairs, and presentations at high schools and colleges to promote the role and attract interest from potential candidates.

Robust Training Programs: Collaborate with local academic institutions offering pharmacy technician programs. These students often struggle to find hospital sites for their externships, so creating opportunities for them can benefit both the candidates and the department to evaluate if it’s a good fit.

In summary, pharmacy technicians are crucial to running safe and efficient pharmacy operations. Addressing the shortage with these strategies can help ensure a steady supply of skilled professionals.

Pharmacy design is evolving, driven by advancements in technology, a deeper understanding of workflow optimization, and an increased focus on medication safety and staff well-being. The future of pharmacy design depends on a comprehensive approach that integrates state-of-the-art technology, ergonomic principles, and a patient-centered mindset. This article explores the trends and key considerations shaping the pharmacy of tomorrow, highlighting how strategic design improvements can enhance efficiency, ensure safety, and improve patient outcomes.

Embracing Technological Advancements

Integration of cutting-edge technology is paramount in modern pharmacy design. As pharmacy operations expand and grow in complexity, leveraging technology is critical to function. Automated dispensing systems, robotic medication management, and advanced inventory tracking should not be futuristic concepts, but indispensable components of an efficient pharmacy. These technologies streamline operations, reduce errors, and allow staff to focus on patient care.

Impact of Technology on Pharmacy Operations

• Reduced Medication Errors: One study reported a 63% decrease in potential adverse drug events and a 96% relative reduction in dispensing errors after implementation of barcode technology in a hospital pharmacy.¹
• Increased Efficiency: One hospital pharmacy achieved a 7-minute turnaround time and an average accuracy of 99.48% after implementation of an automated dispensing system.²
• Inventory Optimization: Upgrading dispensing technology and properly managing automated dispensing cabinets can decrease inventory stockouts and generate significant cost savings through enhanced inventory management.³

Prioritizing Ergonomics and Staff Well-Being

The physical design of a pharmacy must prioritize staff well-being, as studies show that employee satisfaction is linked to higher customer satisfaction.⁴ Ergonomically designed workstations analogous to airplane cockpits reduce physical strain and increase productivity. Poor working conditions have been shown to contribute to medication errors.⁵ Survey data found that pharmacy personnel who are at risk of experiencing high distress have a twofold risk of making a medication error.⁶ Intentional staff-centered design can mitigate these risks.

Designing for Medication Safety and Regulatory Compliance

Good workflows significantly impact medication and patient safety, so it should come as no surprise that safe medication practices should be at the forefront of pharmacy design. In a global systematic review, the World Health Organization reported a 5% prevalence of preventable medication-related harm.⁷ One study at an academic hospital observed that 21% of medication errors went undetected by pharmacists during verification.⁸ Designing workflows that emphasize safety, combined with a commitment to regulatory compliance, ensures patient protection.

Enhancing Collaboration and Communication

Effective communication and collaboration among pharmacy staff and other healthcare professionals are essential for delivering high-quality care. Convenient access to patient data improves medication management and reduces errors stemming from miscommunication. Pharmacy design should incorporate spaces and workstation lines of sight that facilitate teamwork and information sharing. Quiet workspaces that promote concentration and minimal interruptions are crucial for tasks that require high levels of focus. Distractions are linked to 45% of medication errors.⁹

Conclusion

Thoughtful pharmacy design has immense potential to transform healthcare and pharmacy operations. By embracing technology, prioritizing ergonomics, ensuring medication safety, and fostering collaboration, we can create efficient pharmacy environments that deliver high-quality patient care, ultimately improving patient outcomes.

References:

1. Poon EG, Cina JL, Churchill W, et al. Medication Dispensing Errors and Potential Adverse Drug Events before and after Implementing Bar Code Technology in the Pharmacy. Annals of Internal Medicine. 2006;145(6):426. doi:https://doi.org/10.7326/0003-4819-145-6-200609190-00006
2. Temple J, Ludwig B. Implementation and evaluation of carousel dispensing technology in a university medical center pharmacy. American Journal of Health-System Pharmacy. 2010;67(10):821-829. doi:https://doi.org/10.2146/ajhp090307
3. Labuhn J, Almeter P, McLaughlin C, Fields P, Turner B. Supply chain optimization at an academic medical center. American Journal of Health-System Pharmacy. 2017;74(15):1184-1190. doi:https://doi.org/10.2146/ajhp160774
4. Chamberlain A, Zhao D. The Key to Happy Customers? Happy Employees. Harvard Business Review. Published August 19, 2019. https://hbr.org/2019/08/the-key-to-happy-customers-happy-employees
5. Pharmacy Workplace and Well-Being Reporting (PWWR) PWWR Report X Second Quarter 2024. American Pharmacists Association; 2024:1-11. Accessed September 24, 2024. https://www.pharmacist.com/Advocacy/Well-Being-and-Resiliency/pwwr
6. Pharmacy Staff | Mental Health Resources | Rising Stress Levels. National Association of Boards of Pharmacy. https://nabp.pharmacy/initiatives/pharmacy-practice-safety/mental-healt…
7. World Health Organization. Global Burden of Preventable Medication-Related Harm in Health Care. World Health Organization; 2024.
8. Cina JL, Gandhi TK, Churchill W, et al. How Many Hospital Pharmacy Medication Dispensing Errors Go Undetected? The Joint Commission Journal on Quality and Patient Safety. 2006;32(2):73-80. doi:https://doi.org/10.1016/s1553-7250(06)32010-7‌
9. Cohen MR, Smetzer JL. Safe Practice Environment Chapter Proposed by United States Pharmacopeia; Sulfamethoxazole/Trimethoprim and Lisinopril Hyperkalemia. Hospital Pharmacy. 2009;44(3):210-213. doi:https://doi.org/10.1310/hpj4403-210

In hospital settings, medication reconciliation stands as a cornerstone in patient safety efforts, ensuring accurate medication histories and preventing adverse drug events. Pharmacy technicians play a pivotal role in this process, offering indispensable support to pharmacists and healthcare teams. As hospital pharmacy leaders and executives navigate the complexities of healthcare delivery, harnessing the full potential of pharmacy technicians in medication reconciliation becomes paramount for optimizing patient outcomes and operational efficiency.

The Role of Pharmacy Technicians in Medication Reconciliation

Pharmacy technicians are instrumental in ensuring comprehensive and accurate medication reconciliation processes within hospital environments. Their responsibilities include gathering medication histories from patients and caregivers, verifying medication lists, and documenting relevant information for pharmacists and clinicians. By meticulously reviewing discrepancies and collaborating with other healthcare providers, technicians help mitigate risks associated with medication errors and improve overall patient safety.

Moreover, pharmacy technicians are adept at utilizing technology-driven solutions for reconciling medications across transitions of care, such as admissions, transfers, and discharges. Their proficiency in pharmacy information systems and electronic health records enables them to streamline workflows and maintain up-to-date medication records, thereby supporting seamless transitions and continuity of care for patients.

Upson Regional Medical Center (URMC) streamlined their medication reconciliation processes in 2021 when they deployed a single pharmacy technician to the Emergency Department (ED) to assist nursing with obtaining medication histories. This initiative resulted after experiencing increased and continuous reports of medication errors related to medication reconciliation. One-year post implementation, their rate of medication errors related to inappropriate or inaccurate medication histories had reduced by 80%. To this date, URMC has added a second pharmacy technician to the ED, allowing seven-day coverage, and have achieved the Leapfrog standard for medication reconciliation. Heather Riggins, Director of Pharmacy at URMC, states that hiring competent pharmacy technicians and ensuring they are trained up to obtain the best possible medication history is critical.

Strategies for Hiring Qualified Pharmacy Technicians

To bolster medication reconciliation efforts, hospital pharmacy leaders should adopt strategic approaches for hiring qualified pharmacy technicians:

1. Competency-Based Recruitment: Implementing competency-based assessments during the hiring process ensures that candidates possess essential skills in medication reconciliation, attention to detail, and proficiency in pharmaceutical software systems. URMC administers a didactic exam that includes matching generic/trade names for the top 200 drugs, identifying appropriate indications for medications, and hypothetical case studies for critical thinking skills.

2. Collaborative Hiring Practices: Involving pharmacists and competent pharmacy technicians in the recruitment process facilitates the selection of candidates who align with the hospital’s patient safety goals and organizational culture. URMC utilizes peer interviews for all hiring candidates, which includes a tour of the pharmacy and hospital. This gives our entire department buy-in on potential new hires. During the tour, staff can observe how the interviewing candidate presents themselves, interacts with others in the organization, and communicates in a more laid-back setting versus at the head of table. Additionally, the peer interview team conducts a mock patient scenario for medication reconciliation to test the candidate’s attention to detail and communication skills.

3. Continued Professional Development: Emphasizing the importance of ongoing education and certification encourages pharmacy technicians to stay abreast of evolving practices in medication reconciliation and enhances their contribution to patient care. URMC candidates are encouraged to obtain specialized training and receive reimbursement for these efforts.

Developing a Strong Training Program

Creating a structured training program is integral to preparing pharmacy technicians for their role in medication reconciliation:

1. Comprehensive Orientation: Offering thorough orientation sessions familiarizes new hires with hospital protocols, medication reconciliation procedures, and the importance of patient safety standards. Society of Hospital Medicine Train the Trainer Materials provides an excellent supplemental guide for training.

2. Hands-On Experience: Providing opportunities for practical training under the supervision of experienced pharmacists and pharmacy technicians allows new hires to refine their skills in medication history taking, data entry accuracy, and effective communication with patients and healthcare teams.

3. Continuous Feedback and Evaluation: Implementing regular performance evaluations and feedback sessions enables technicians to identify areas for improvement and ensures adherence to quality standards in medication reconciliation practices.

4. Integration of Technology: Incorporating training modules on pharmacy information systems and electronic health records equips technicians with the necessary tools to facilitate efficient medication reconciliation processes.

By investing in the recruitment of skilled pharmacy technicians and cultivating a culture of continuous learning and development, hospital pharmacy leaders can strengthen medication reconciliation initiatives. Empowering pharmacy technicians with the knowledge, resources, and support they need fosters collaborative healthcare environments where patient safety remains the top priority.

The role of pharmacy technicians in medication reconciliation is indispensable for ensuring accurate medication histories and promoting patient safety in hospital settings. Through strategic recruitment practices and comprehensive training programs, pharmacy leaders can harness the full potential of technicians to optimize medication reconciliation processes and enhance overall healthcare outcomes. By prioritizing these efforts, hospitals can uphold the highest standards of care and improve the well-being of patients across transitions of care.

References:

https://www.hospitalmedicine.org/clinical-topics/medication-reconciliat…