osama tabbara, r.ph., bcnsp, emba senior director ... director, department of pharmacy services ......
TRANSCRIPT
Osama Tabbara, R.Ph., BCNSP, EMBASenior Director, Department of Pharmacy ServicesCleveland Clinic Abu Dhabi, UAE
Disclosure InformationEstablishing a World Class Pharmacy: The Cleveland Clinic Abu Dhabi ExperienceOsama Tabbara
I have no financial relationship to disclose
&
I will not discuss off label use and/or investigational use in my presentation.
Learning Objectives
• At the completion of this activity, you will be able to:
• Be aware of various initiatives used in Cleveland Clinic Abu Dhabi when establishing the pharmacy services.
• Describe the space, design, workflows, and manpower needed for to establish world class pharmacy.
• Identify the technologies used to enhance medication safety and quality
Day #1: March 2015
• 360-bed facility
• Five centers of excellence:
• Heart and vascular medicine
• Neurological medicine
• Digestive diseases
• Ophthalmology
• Respiratory and critical care
• 170 Physicians
• 78 Pharmacy Caregivers
• 1700 Nurses
"Placing patients first is our highest priority.
Patients are the reason we exist and the reason
we come to work each day."Delos M. Cosgrove, M.D.
Chief Executive Officer and President
Cleveland Clinic Health System
جميعاومن أحياها فكأنما أحيا الناس
And whoever saves one - it is as if he had saved mankind entirely
Al-Maaida, Aya 32
Cleveland Clinic Abu Dhabi Department of Pharmacy Services
• Our Mission:
• To provide safe and optimal medication therapy through compassionate, patient-centered care of the highest quality.
• Our Vision:
• To be a world class leader in Pharmacy care.
• Our Values:• “Patient First” care through Cleveland Clinic Abu Dhabi
shared values of Quality, Compassion, Integrity, Teamwork, Service, Innovation and Stewardship
• S = Sincerity
• T = Trust / Transparency
•A = Accountability
•R = Respect
We are Committed to STAR
cy
• Design the medication use system based on highest technologies
• Patient-centered pharmacist practice model / PPMI*
• Spread the culture of medication safety at regional level
• To lead the transformation of Pharmacy landscape in the gulf region and beyond
*Pharmacy Practice Model Initiative
Major Programmatic Goals
CCAD Pharmacy
• Granted HiMSS Stage 6 License• Stage 7 Enabled
• Only 5% of USA hospitals are HiMSS stage 7
One in Canada
3 hospitals in Asia
3 hospitals in Europe
The Road Ahead
2015
2016
2017 Ramp up and research
Persistent Forward Progress
Commitments to Safe Startup Operation
•Research & Innovation
• IV Remote Verification
•PGY-2 Residency
•Out-patient Robotics
• Introducing IV Robotics
•PGY-1 Residency
•ACPE providers
•Activation of Satellite Pharmacies
•1,000 Scheduled Visits
•100 Inpatient Census11
Size in m square Size in ft Square
Out-Patient Pharmacy 520 m2 5,597 ft2
In-Patient Pharmacy 1,060 m2 11,410 ft2
4 Satellites Pharmacies 246 m2 2,648 ft2
TOTAL 1,826 m2 19,655 ft2
Pharmacy Surface Area
Quality & Transformational Caregivers
• We hire non-traditional Caregivers• Committed to the mission of the department
• Our ABC for recruitment• A: Attitude
• B: Background
• C: Communication
Recruitment Criteria
• No Nepotism (Wasta)
• “If you meet the criteria, you have the right to sit for an interview”
• Start the interview with disclosure and intention of fairness
• STAR interviews
• Source references
• It took us 4 years to recruit 68 caregivers
• Interview to on-boarding: 9-15 months per Caregiver
CCAD Pharmacy Manpower & Demography41 Pharmacists, 27 Technicians, 2 Analysts,
8 Distribution Agents
Male/Female1:1
62% Pharm.D.31% at least PGY-1
30% with Master36% with Board
60% USA trained40% MEA trained
What make most pharmacy leaders awake at night?
• Maintaining employee engagement
• What is happening in the IV Room
• The turn-around time in the out-patient pharmacy
• Stock shortages
• How to prevent medication errors
• The Internal Factors:• Vision • People (No inheritance)• Name/benchmark• Location• Package• Technologies
• The External Factors:• Regulations• Logistics• Regional political & economical instability
Internal versus External Factors
Facts
• Pharmacists lose skills when not
performing patient-centered activities:
Drug information
Kinetics
Rounds
Ambulatory Clinics
The Gulf Experience from the USA• 5% increase per year in out-patient
pharmacy orders
• 2.5% increase per year in in-patient hospital drug orders.
The Gulf Experience
The Future
• System improvement through advanced informatics and automation should be the focus of every pharmacy leader
• Leverage the IT talents of Pharmacists
Challenges & Lessons Learned
• Integration between Middle Eastern and Western experiences takes one year
• Strong Operational staff are as important as strong Clinical People
• Low turnover retards career growth!
• Maintaining Male: Female at 1:1 is very difficult
• Challenges in recruiting local operational Pharmacists• Shift demands
In-Patient FTEs Benchmarks
Pharmacists per
100 beds
Technicians per
100 beds
100-199 beds 11.7 9.7
200-299 beds 12.1 10.6
300-399 beds 12.1 10.8
400-599 beds 11.1 9.6
> 600 beds 11.5 10
Am J Health-Syst Pharm, Vol 72, July1, 2015
FTEs* BenchmarkPharmacists
per 100 beds
Technicians
per 100 beds
ASHP** Survey
(300-399 beds)12.1 10.8
Cleveland Clinic
Main Campus
1300 beds
9.5 10
3 Saudi Hospitals
(1800 beds)13 9
Cleveland Clinic
Abu Dhabi
(120 beds start up)
11.6 13.3
* FTEs: Full Time Equivalents
**American Society of Hospital Pharmacists
In-patient Pharmacy Cleveland Clinic Abu Dhabi FTE* Model
• First 100 beds:• 14 Pharmacy Technicians
• 12 Pharmacists
• FTEs per 100 functioning beds above 100• 10 Pharmacists
• 10 Technicians
• FTEs per each Satellite Pharmacy • 1-2 Pharmacists and 1-2 Technicians
*Full Time Equivalents
Order Processing per Pharmacist
• 150 to 300 order verifications per Pharmacist per 8-hour shift
• Prescriptions filled per In-Pharmacist:• 110 per day = 13 /hour
UHC list serve, 7 USA hospitals, 2015
IT* Manpower Design
1. C. A. Pedersen et al., Am J Health-Syst Pharm-Vol , 26 May 15,2009
* IT: Information technology
**ASHP: American Society of Hospital Pharmacists
Number of FTEs
ASHP** Survey 1 IT pharmacist + 1 IT technician per
100 beds1
Cleveland Clinic Health System, Ohio 29 IT pharmacy staff
Cleveland Clinic Abu Dhabi 3 IT pharmacists + 4 IT analysts
The Medication Use Process in the In-Patient
•
Robotic Packager
Selection & Procurement
Automated Storage Cabinets
Medication Tracking/Monitoring/Documentation
Medication Administration
Computerized Prescriber Order Entry
Dispensing
Knowledge Portal
Wasting Controlled
Medication
• 97.1% of USA hospitals ADMs
• 100% of hospitals (>300 beds) use ADMs
Am J Health-Syst Pharm, Vol 72, July1, 2015
Automated Dispensing Machines (ADMs)
Carousels
• 21.1% of USA hospitals use carousels
• 40.7% of hospitals (>300 beds) use carousels
Am J Health-Syst Pharm, Vol 72, July1, 2015
18%
21%
17%
17%
18%
18%
19%
19%
20%
20%
21%
21%
22%
2011 2014
Pyxis to Bed Ratio
•1 Pyxis per 9-11 beds in CCAD* compared to 1 Pyxis per 16-18 beds in North American hospitals
*Cleveland Clinic Abu Dhabi
Challenges
• It takes at least 6 months for nurse to accept ADMs
• It takes one year for physicians to digest the concept of Pyxis Anesthesia stations.
Inpatient Dispensing TAT*
41
10 minutes with ADMs** compared to
50 minutes with traditional dispensing
*TAT: Turn-Around Time
** ADMs: Automated Devices Machines
Barcoding
• Rate of all potential dispensing errors decreased by 86-97% (P<0.001)
• For inventory purposes (Pharmogistics, out-patient inventory)
• Assure safety in loading/selecting drugs in Pyxis
• For medication tracking (Medboard)
• e-MAR purposes, Infusion pumps, BCMA*.
Eric G. Poon et al., Annals of internal med 2006, 145 (6) 426-34
*Bar Code Medication Administration
Challenges with Barcoding
Lack of regional NDC*
Difficulties in barcoding
Large Volume Parenterals
Multiple Dose Vials
* National Drug Code
Benchmarks in Clean Rooms
• 65% of USA hospitals have USP 797 compliant clean rooms
• 93.5% of USA hospitals (> 600 beds) are compliant
Am J Health-Syst Pharm, Vol 72, July1, 2015
Automated PN Compounding
• 60% of USA hospitals (> 600 beds) use PN Automated Compounding
Am J Health-Syst Pharm, Vol 72, July1, 2015
Ambulatory Pharmacy Services
Medication Dispensing to Clinics, Emergency, Discharge
Retail OTC* Sales
Patient Counseling & Education
24/7
Services
* OTC: Over The Counter
Manpower Design
• We are 18 Pharmacists and 13 technicians
• 2 Pharmacists + 1 Technician safely process, fill, dispense and counsel 30-35 patients per hour
• More counseling stations, more pharmacists
• Prescriptions filled per Out-Patient Pharmacist: (UHC list serve, 7 USA hospitals, 2015)
• 87 Rx per shift = 11 / hour
Facts
• 8 x increase in number of out-patient deaths due to errors compared to 2 x increase in hospital deaths
• From the Institute of Medicine (IoM), 2010
• Single MER event in the out-patient pharmacy is capable of generating enormous negative publicity
Ambulatory Pharmacy: Activation Challenges
• IT integrations between systems
• Ambulatory Pharmacy technologies are more complex than in-patient pharmacy
• Forecasting of needed medications in a multispecialty hospital
• Compliance in ordering formulary compared to non-formulary medications!
Pharmacotherapy Services
• Highly trained
• Board certified with ≥ 1 residency training
• 3 Senior Pharmacotherapy Specialists
• 3 Pharmacotherapy Specialists
Fully integrated with the in-patient team
Scope of Pharmacotherapy Services
• Patient care rounds and consult services• Heart, ICU, ID, Medicine, ED
• Parenteral Nutrition
• Therapeutic drug monitoring
• Formulary management
• Ambulatory anticoagulation management
• 16.8% of USA hospitals have Anticoagulation Clinic
• 54.3% of hospitals (>600 beds) have Anticoagulation Clinic
Am J Health-Syst Pharm, Vol 72, July1, 2015
11%
16%17%
0%
5%
10%
15%
20%
2012 2103 2014
Pharmacy-Based Anticoagulation Clinic
Pharmacy-Based Future Ambulatory Care Clinics
Anticoagulation
Medication Therapy Management
Diabetes Clinic
Hypertension & Lipid Control Clinic
Pain Management Clinic
Travel & Vaccination Clinics
Smoking Cessation Clinic
Controlled Medications: Restriction Levels
Controlled Medication Restriction
Level
Narcotic Medications
#37
Controlled Drug Class A (CDA)
#73
Controlled Drug Class B (CDB)
#56
Challenges
*HAAD: Health Authority of Abu Dhabi
*MOH: Ministry of Health
***CCAD: Cleveland Clinic Abu Dhabi
• HAAD*/MOH** regulations don’t consider automation & informatics to manage controlled meds
• Culturally diverse Clinical Caregivers at CCAD*** who are not used to UAE regulations
• e.g. Saving Empty Ampoules/ Vials
Overcoming Challenges
• Partner with regulators and existing providers
• HAAD approval to automate controlled medications management
• Intensive plan for Caregivers training & education
Use of Pyxis Far exceeds Regulator’s Requirement
Retrieval requires a witness & documentationDual sign-off in Pyxis with blind count
Controlled medication wastageDual sign-off in Pyxis
Smart Sinks for Controlled Meds Waste
Offering more comfort to regulators
Securing & safe preventing any diversion
Avoiding pollution compared to other methods
Continuous Improvement: Management of Broken Ampoules
0
2
4
6
8
10
12
April May June July
BrokenAmpoules (#)
Reduce number of
ampoules in patient care
units
Supporting the fragile
ampoules by padding the
pockets
Mats were placed beneath
each Pyxis
Camera over each Pyxis
to protect caregivers
Satisfaction: “the contentment one feels when one has
fulfilled a desire, need, or expectation.”
Employee satisfaction is related to the organization
Engagement: “employee is involved in, enthusiastic
about, and committed to his or her work.”
Engagement is driven by the local work group environment
Satisfaction versus Engagement
Employee Engagements
• Allows for strong culture of learning and growth
• Develop subject matter experts & future leaders• Amina Al-Hammadi- MBA
• Rami Ismail - Anticoagulation Therapy Management Program
• Osama Abu Tabar - Public Healthcare Quality examination
• Lisa Brennan - Geriatric Certification Exam
• Khalid Abdel Dayem - 4 EPIC Willow certifications
• Lana Hussein - EPIC Willow Certification
• Omar Chehab - EPIC Willow Certification
• Ziad Sadiq - EPIC Willow Certification
• Ahmad Chaker - EPIC Willow Certification
• 3 caregivers completing MBA, MHA and EMHA
Gallup-Q12
Basic Needs
Individual Contribution
Teamwork
Growth
Q12. Opportunities to learn and grow
Q11. Progress in last six months
Q10. I have a best friend at work
Q9. Coworkers committed to quality
Q8. Mission/Purpose of company
Q7. At work, my opinions seem to count
Q6. Someone encourages my development
Q5. Supervisor/Someone at work cares
Q4. Recognition last seven days
Q3. Do what I do best every day
Q2. I have materials and equipment
Q1. I know what is expected of me at work
Our Pharmacy Gallup Grand Mean
4.05
4.89 4.83
4.29
Grand Mean 2012 Grand Mean 2013 Grand Mean 2014 Grand Mean 2015
Engaged
Caregivers
Engaged
Patients
1. Increased retention 2. Less Sick Calls 3. Productivity 4. Profitability 5. Improvements in safety 6. Customer Engagement
Why is Caregivers’ Engagement Important?
Engagement’s Business Outcome
From Our Culture: Daily Huddles
• A time that is never missed
• Fun AM ice breaker
• Transparent open forum
1. Become genuinely interested in other people
2. SMILE, SMILE, SMILE
3. Remember a person’s name
4. Be a good listener
5. Talk in terms of other person’s interest
6. Make the other person feels important
How to Win Friends and Influence People?
From the Book by Dale Carnegie
6 Ways to Make People Like You
Advice to the leaders
Be popular: smile, laugh, and have fun!
Open door
Let others teach you
Solutions found only through brainstorming
Watch yourself: Be a role model
Early sensing lack of engagement
Focus on Strengths Culture
Mohammad A. Siddiqui, PharmD.,MBA | Manager, Inpatient Pharmacy | Department of Pharmacy Services
Cleveland Clinic Abu Dhabi | P.O. Box 112412 | United Arab Emirates | Mobile No. 971-052-699-7757
Office No. +971 2 501 9999 Ext. 40934| Office fax No. +971 2 4108223. Email: [email protected]
My top 5 strengths are: Developer, Responsibility, Empathy, Connectedness, Relator
Reference: “The Strengths Finder”
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