prioritizing care - allocation of clinical pharmacist ... · (medication cost ... may be...

Prioritizing Care

Allocation of Clinical PharmacistResources

Robert P. Granko, PharmD, MBA, FASHPApril 26, 2018

Director of PharmacyMoses Cone Hospital, Greensboro, NC, USA

[email protected]

Cone Health Residency Program Director, Combined MS/PGY1/PGY2 Health System Pharmacy Administration

Associate Professor of Clinical EducationUNC Eshelman School of Pharmacy

Chapel Hill, NC, USA

Agenda

• Allocation of Clinical PharmacistResources

• Balancing Pharmacy Benchmarking and Reform

Financial Disclosure

The presenter has no financial relationships or conflicts of interest to disclose.

Moses H. Cone Memorial Hospital

Alamance Regional Medical Center

Wesley Long Hospital

Annie Penn Hospital

Women’s Hospital

Behavioral Health Hospital

236 beds

175 beds

110 beds

134 beds

80 Beds

536 beds

Moses Cone Hospital and Cone HealthDepartment of Pharmacy

Moses Cone HospitalDepartment of Pharmacy• 137 Employees (112 FTEs)

• Growing: Specialty Pharmacy (34 FTEs)

• 37 Pharmacists• 50 Technicians

• 14 Administrative Staff• 12 Pharmacy Residents (FY17)• FY16 Expense Budget: $39M

• Salary Expense: $7.2M• Drug Expense: $25M

• FY16 Revenue Budget: $122M

Cone Health Pharmacy

• 370 Employees (300 FTEs)• 125 Pharmacists

• 179 Technicians• 30 Administrative Staff

• 17 Pharmacy Residents • FY16 Expense Budget: $135M

• Salary Expense: $19M• Drug Expense: $103M


ObjectivesReview challenges and opportunities facing hospitals and health care systems today

Describe the development and deployment of an objective methodology to assign Clinical Pharmacist personnel

Demonstrate the annual application of and provide some analysis across multiple settings

Review the development of future criteria used in the assessment model

Nursing shortages, continued physician and medical specialist hiring, and technological investments are accelerating expense growth.

Generating sufficient operating margin to support our clinical, education, and research mission Low reimbursement rates drive slowed revenue growth despite consistent volumes Evolving standardization and operating model Clinical integration and care delivery transformation to stabilize new affiliate operations and

developing model for future success Keeping pace with evolving population health landscape Sustained pressure to contain costs, ensure clinical and operational efficiencies, and search for

new revenue sources Timely access for urgent and emergent – exceedingly longer wait times for less urgent Narrow scope of services covered by provincial insurance plans Aging populations, growing universal hospital insurance costs

Continuous Challenges and Opportunities

References : Not‐for‐profit and public healthcare – US, https://theconversation.com/how‐healthy‐is‐the‐canadian‐health‐care‐system‐82674

374 employees (321 FTEs) Staff:

123 Pharmacists 150 Technicians 71 Administrative Staff 30 Pharmacy Residents (31 FY15)

FY15 Expense Budget: $161.6M Salary Expense: $26.2M Drug Expense: $121.9M

FY15 Revenue Budget: > $500M Charge on Administration

Excellence in patient care Integrated, collaborative structure - shared

vision and mission Philosophically and financially committed to

each other's success Loyalty to the advancement of the individual

aims of both organizations Unquenchable desire to establish national

excellence in patient care, teaching, and point of care research

Acknowledgment that pharmacy students and pharmacy residents are vital components to the delivery of patient care offered by the UNC Medical Center as well as the teaching, service and research missions of the Eshelman School of Pharmacy

UNCMC Department of Pharmacy Stats Partnership In Patient Care

UNC Hospitals Department of Pharmacy

At a Glance Lack of an objective and standardized tool for determining the

allocation of resources 2010 Pharmacy Practice Model Summit 2012 AJHP publication of the Method to Determine Allocations of Clinical

Pharmacist Resources Goal(s): Novel, self-developed, staffing application model that encompasses essential,

measurable components of the daily workload of acute care clinical pharmacist specialist practitioners

Built metrics to objectively support our decisions to grow and in some cases realign resources to best meet patient care staff engagement

Front-line staff involvement and leadership through task forces and subgroups

CC AA TT CC HHp™

Reference: Robert P. Granko, Lindsey B. Poppe, Scott W. Savage, et.al. Am J Health‐Syst. August 2012, 69 (16) 1398‐1404

Assessment Model Defined(Census): Average Daily Census

UHC‐Truven Health Analytics provides descriptions of the MS‐DRGs and the associated Pharmacy Intensity Weight (PIW) annually.

A service‐specific pharmacy intensity score (SSPIS) for each MS‐DRG is calculated for the top 20 most common MS‐DRGs within each service.

The overall SSPIS is performed by summing SSPIS values for all MS‐DRGs, then divided by the total number of discharges for those top 20 MS‐DRGs

(Teaching): the total number of learners including pharmacy residents and students, rotating through a given service and BPS recognition

(Medication cost (Charge)): the total medication charge

(High‐Priority Medications): the total number of high‐priority medications that require a higher level of pharmacist initial/ongoing review and follow‐up

Census

Acuity

TeachingCharge

High-Priority Meds

Individual Perspectives Combined Perspectives

The sum is greater than the parts!

?

Analysis – 2013 Methods and Now

Five metrics of pCATCH were collected through available database from UNC Hospitals, and covered the period January 1 2013 – December 31 2013.

All collected data was analyzed exactly as described in the 2010 original manuscript with a few exceptions: Only 9 months (1/1/13 - 9/30/13) of top 20 most common MS-DRGs, with the number of discharge associated

within each service unit were included in calculations of an overall service-specific pharmacy intensity score (SSPIS).

The medication cost was calculated based on the total medication charge value. This methodology is different from 2010 pCATCH, which defined the medication cost as a medication acquisition cost.

The most updated “High-Priority Medications” list was used for assessing the use of High priority medication charges, which resulted in adding 7 new medications and 2 therapeutic classes (antifungals and antiretrovirals) to our analysis. In addition, this research has counted the total number of charges for high-priority medications, rather than the total order of high-priority medication (2010 methodology) due to limited database access.

Introduction of the revenue metric which reflects the outpatient prescription revenue derived from service level referrals.

Applied methodology academic medical center setting as well as a large community teaching hospital (CTH) Further, we have used this model to integrate a smaller community teaching hospital into a large CTH

CMI and PIS Case mix index (CMI) is not a valid

patient indicator for departments of pharmacy Supported in pharmacy literature;

competitors use it An acuity adjustment is needed

Enables direct comparison among institutions, regardless of patient mix

CMI is based on overall resource consumption and not adequate to use for medication expense

CMI assigns similar acuity ratings to patients who require vastly different levels of medication resources and knowledge work to achieve a positive patient outcome – quality and safety

Resource-based relative value intensity (R-BRVI) grouping system that utilizes pharmaceutical resource consumption data to produce DRG-specific drug use resource requirements A Diagnosis‐Related Group (DRG) is a statistical system of

classifying any inpatient stay into groups for the purposes of payment.

The DRG classification system divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement

Data collected Truven Health clinical database to assign a weight to every DRG (0.1 to 100; DRG with highest median drug cost per admission assigned value of 100)

Sum of (DRG intensity weights x DRG volumes)/Total Admission = PIS

Case Mix Index (CMI) Flaws Pharmacy Intensity Score (PIS)

Rough SS, et al. Am J Health‐Syst Pharm. 2010; 67:300‐11 and https://www.healthlawyers.org/hlresources/Health%20Law%20Wiki/Diagnosis‐related%20group%20(DRG).aspx

Case Mix IndexCase Mix Index (CMI):

CMI is a relative value assigned to a diagnosis-related group of patients in a medical environment.

CMI is used in determining the allocation of resources to care for and/or treat the patients in the group.

May be incorrectly applied to approximate – undervalued PIS for Pharmacy-Specific Acuity and Medication Resource Consumption

^ www.cms.gov (accessed 9.2.14) *Truven Health Analytics; For discharges from October 1, 2013 to September 30, 2014 (based on MS‐DRG version 31)

Pharmacy Services at the University of North Carolina Hospital with at least four metrics ranked in Top 20 per

category for 2013

UNC Hospitals - Top Total Composite Scoring Services

2010

2 2

2011

2013

Infectious Disease

Trauma SurgeryCardiac Surgery

NeurosurgeryMedicine ICUMed Heme/OncBone Marrow TransplantNeonatal ICUMed Pulmonary

Cardiac SurgeryInfectious Disease

Trauma SurgeryMed PulmonaryNeonatal ICUBone Marrow TransplantMed Heme/OncMedicine ICUNeurosurgery

Neonatal ICU

Trauma SurgeryCardiac Surgery

Med Pulmonary

Infectious Disease

Medicine ICUMed Heme/OncBone Marrow Transplant

Neurosurgery

Observed Changes in CompositeScore from 2010 to 2013

+2+2+2+2

+3 +3

+2Cardiac Surgery

Geriatrics

Neurology

Ped Newborn

General MedicineVascular Surgery

Surgery TransplantPed PulmonaryPed Thoracic Surgery

(+3)

(+2)

(+1)

(‐1)

(‐2)

No Change

Total Composite Score Changes (n=36*)

*n/a are excluded from this view

Top 20 Daily Patient Census 2013

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Patient Acuity Across 2010, 2011 and 2013

‐43%

Med Heme/OncPed CardiologyMed L Hospitalist

Ped HematologyPed Thoracic Surgery

Surgery Transplant

Medicine ICUCardiac SurgeryBone Marrow Transplant

‐12%‐3%

‐27%

‐57%

+103%‐40%

‐20% +20%

‐36%

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20132010 2011

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OChanges in PIS Across all

UHC Institutions% changes in PIS from 2013

Ref: UHC/Truven

UNC Hospitals Learner Volumes Changes from FY 2008 - 2015

+152%

2008‐2009 2009-2010

+56%

+129%

+100%

2014-20152013-20142012-20132011-20122010-2011

Total # RotationsTotal # Residents #APPE#PGY1

Neurosurgery (NSICU)

Cardiac Surgery

Family Medicine

Infectious Disease

Med Nephrology

Trauma Surgery (SICU)

Vascular Surgery

Medicine ICU

Med Heme/Onc

Med Cardiology

2013 Order Count2011 Order Count2010 Order Count

High Priority Medications across 2010, 2011 and 2013

Service 2010 Order Count 2011 Order Count 2013 Charge Count 2013 Order Count (*)Med Cardiology 2233 2245 10785 5256Med Heme/Onc 3493 3476 15555 4625Medicine ICU 2344 2788 9160 3422Vascular Surgery 882 1216 7764 2846Trauma Surgery (SICU) 765 2949 11688 2830Med Nephrology 1262 1386 7200 2508Infectious Disease 1049 1323 9683 2462Family Medicine 981 1163 6655 2425Cardiac Surgery 673 1022 5893 2378Neurosurgery (NSICU) 837 1323 8462 2335Med Pulmonary 985 1334 9885 2301Med L Hospitalist N/A 812 5536 2272Adult Burns (BICU) 474 1059 14310 2123Neurology 524 1337 8566 2096Ped Hematology 1506 2121 4707 1864General Medicine 892 1311 4735 1761Bone Marrow Transplant 1351 1739 6978 1719Geriatrics 689 725 4908 1670General Medicine‐Liver 885 1050 4713 1534Surgery Transplant 968 1000 4295 1421Med Heart Failure 838 872 5289 1388Ped Newborn Crit Care (NCCU) 1394 12048 5073 1207Psychiatry 1190 1343 6160 1111Med J Hospitalist N/A 390 3063 1050Ped Critical Care (PICU) 777 2880 2886 1011Thoracic Surgery 643 1077 4167 864Haspitalist Teaching 461 553 2182 741Ped General 395 695 1139 438Ped Cardiology 154 521 814 430Ped Burns 57 132 567 366Ped Pulmonary 376 282 1669 363Ped Hospitalist 22 411 836 354Ped Gastroenterology 359 2022 636 182Ped Nephrology 195 231 482 182Ped Newborn 35 28 307 170Ped Thoracic Surgery 53 148 304 119Carolina Donor Services N/A N/A 25 20Ped Neurology 60 66 6 4Ped Endocrinology 3 6 1 0

Revenue Generating Service Lines

$450,000

$400,000

$350,000

$300,000

$250,000

$200,000

$150,000

$100,000

$50,000

0

$100,000

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CC AA TT CC HHprr

$100,000

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$81,616

SUR TRANSPLANT

$87,378

MED GENERAL BURNETT

$125,137

MED HOSP L

$200,473

MED HEMATOL/ONCOLOGY

$400,931Total Revenue >$80,000


Moses Cone HospitalDepartment of Pharmacy• 137 Employees (112 FTEs)

• Growing: Specialty Pharmacy (34 FTEs)

• 37 Pharmacists• 50 Technicians





• 370 Employees (300 FTEs)• 125 Pharmacists

• 179 Technicians• 30 Administrative Staff

• 17 Pharmacy Residents • FY16 Expense Budget: $135M

• Salary Expense: $19M• Drug Expense: $103M


2015 Moses Cone Hospital

2016 Moses Cone Hospital PLUS Women’s Hospital

ConclusionsChallenges and opportunities facing hospitals and health care systems today – Objective and usable data

Development and deployment of an objective methodology to assign Clinical Pharmacist personnel

Demonstrated the annual application of across multiple settings

Review the development of future criteria used in the assessment model

Prioritizing Care

Balancing Pharmacy Benchmarking and Reform

Robert P. Granko, PharmD, MBA, FASHP

Director of PharmacyResidency Program Director,

Combined MS/PGY1/PGY2 Health System Pharmacy AdministrationMoses Cone Hospital, Greensboro, NC USA

[email protected]

Objectives

Describe commonly utilized benchmarking metrics

Describe the process that could be used to refine pharmacy benchmarking metrics

Leverage vendor methodologies to assist in the development of your benchmarking strategy

Present acuity model application of clinical pharmacist knowledge work across multiple settings


Moses Cone HospitalDepartment of Pharmacy

• 137 Employees (112 FTEs)• Growing: Specialty Pharmacy (34

FTEs)• 37 Pharmacists• 50 Technicians





• 370 Employees (300 FTEs)• 125 Pharmacists• 179 Technicians

• 30 Administrative Staff• 17 Pharmacy Residents

• FY16 Expense Budget: $135M• Salary Expense: $19M• Drug Expense: $103M


Background Challenge Action Steps Results Findings

A Top Issue that Pharmacy Leaders Continue to Face

Pharmacy operational benchmarking using external benchmarking vendors remains atop the list of issuesnew and experienced pharmacy leaders face.

Pharmacy benchmarking information from external vendors consists of numerous generalized data elements that may describe the size, complexity, andefficiency of a department.

Rough SS, et al. Am J Health‐Syst Pharm. 2010; 67:300‐11

Background Challenge Action Steps Results FindingsBackground Challenge Action Steps Results Findings

A Top Issue that Pharmacy Leaders Continue to Face

For many hospital pharmacy departments, external benchmarking is a lagging indicator of department effectiveness and staffing appropriateness.

Factors including: Lack of standardized, agreed upon metrics for demonstrating clinical

pharmacy services; and Difficulties in obtaining accurate, meaningful data from comparator

institutions; and Lack of specificity to emerging and evolving practice model initiatives



We Are All on a Benchmarking and Productivity Journey

*

What’s Happening?

Predictions?

Change?

1

2

3


Goals of Benchmarking ReviewDemonstrate that Moses Cone’s Department of Pharmacy is

focused on high-quality, safe patient care outcomes in a fiscally responsible manner

Seek trust from hospital leadership; recognize that pharmacy is on a quality

improvement journey and is ever focused on deploying

opportunities to gain efficiency in high-quality, safe, value-based patient

care

Ensure our resources are deployed to care for

our sickest patients Ensure accurate representation and

comparison of utilization of FTEs

Provide appropriate skill mix, allowing our

pharmacists and pharmacy technicians to work at the top

of their licenses and certifications, respectivelyWhere and when

appropriate, exercise planned abandonment


Reports, Forms, and DefinitionsComparative

Report Definition

OverviewTypical

Department Functions

Standard Position Titles

Departmental Volumes and

Statistics

Revised: 2013

Benchmarking Report

Benchmarking Report

Calculations

Peer definition: a person who is

equal to another in abilities,

qualifications, age, background, and

social status.

Benchmarking Report

Calculations

Indicator Name

Quarter Calculation

Definitions and Formulas


Pharmacy Intake FormMost recent filedSeries of questions

(40-50)

What services do you perform that

are NOT included?

Peer Characteristic Survey – ASHP – 39 pages and greater than 100 questions

Peer Profile Comparison

Report

Summative report of

your intake form

answers – in percentage

Entity Financial Summary

Gross revenue (inpatient and

outpatient)

Expenses

Reports, Forms, and Definitions


ASHP Peer Characteristic Survey Appendix to effective use of workload and productivity monitoring tools in

health-system pharmacy Examples: Not all inclusive

Hospital Characteristics For your hospital, what is the number of staffed (or operated) beds?

Pharmacy Activity Information For the last fiscal year, what was the total number of inpatient medication orders (new/

modified/discontinued) processed by pharmacy? Staffing Information

How many inpatient FTE pharmacist positions are you currently budgeted for? Medication Preparation and Dispensing

What is the basic philosophy of your current inpatient pharmacy's distribution system (i.e., medication doses prepared and/or dispensed for patients)?


Vendor A Benchmarking Report There are 25 peers included on the Vendor A benchmarking

report run for Moses Cone Hospital Statistically outside those compared against

Moses Cone was not ranked among these selected peers 90th percentile – 28.37 ($2.12M) FTEs/$$ opportunity – WHpU –

Adjusted Patient Days 75th percentile – 32.12 ($2.4M) FTEs/$$ opportunity – WHpU –

Adjusted Patient Days 50th percentile – 36.35 ($2.7M) FTEs/$$ opportunity – WHpU –

Adjusted Patient Days


Action StepsResearchAJHP - Effective use of workload and productivity monitoring tools in health-system pharmacy, parts 1 and 2 -Steve S. Rough, Michael McDanieland James R. Rinehart

NetworkHow to best approach; what have they used in the past and any advice

Time commitmentWork the problemSpread the knowledge

1

2

3 Pharmacy Intake Form Reviewed each question with my

leadership team – Location of FTEs Findings(s):

1. 5 FTEs that were health-system wide were included

2. School of pharmacy clinical pharmacist positions (1.0 FTE) –these will count against you

3. Clarity into cost centers –medication history program (13.9 pharmacy technician FTEs) –admits and discharges

4 Vendor Methodology


Methodology of Vendor AComparative Report Definition Document

Overview, Department Volume and Statistics, etc.

Worked Hours Include Regular and OT hours Staff supervision and meetings Contract hours

Worked hours do not include Non-paid student training hours Pharmacy staff hours charged

elsewhere IV administration hours (not

applicable) Student teaching hours Hours captured in another cost center On-call hours


Summary of Vendor A “Peers” Asked to reach out to 3 of them N=19 (76%) peers have under 250 ADC N=12 (48%) peers have under 200 ADC

N=9 (36%) peers do not offer 340B pricing Adjusted patients days are comparable but with half my

average daily census Many of these institutions are not like comparators (peers) Zeroed in on one peer that I could look at: CMS rank, FTEs, average monthly volumes, charges,

dispenses, order verifications, expenses, etc.


Adjusted Patient Days How does an institution with less than 200 beds produce volume numbers of

hospitals twice its size? Example: XYZ Hospital #3 ranked

Adjusted Volume 13,582 at 160 ADC

Adjusted patient days =

Institutions with higher proportion of outpatient revenue have falsely elevated adjusted volumes

Institutions may have differing mark-up on drugs provided as outpatient arbitrarily increasing revenues

If an institution does not manage its discharge process well (i.e., longer length of stay), its volume is increased and it looks like a higher performer


CMI and PIS Case mix index (CMI) is not a valid

patient indicator pharmacy Supported in pharmacy literature;

competitors use it An acuity adjustment is needed

Enables direct comparison among institutions, regardless of patient mix

CMI is based on overall resource consumption and not adequate to use for medication expense

CMI assigns similar acuity ratings to patients who require vastly different levels of medication resources and knowledge work to achieve a positive patient outcome – quality and safety

Resource-based relative value intensity (R-BRVI) grouping system that utilizes pharmaceutical resource consumption data to produce DRG-specific drug use resource requirements

Data collected Truven Health clinical database to assign a weight to every DRG (0.1 to 100; DRG with highest median drug cost per admission assigned value of 100)

Sum of (DRG intensity weights x DRG volumes)/Total Admission = PIS

Case Mix Index (CMI) Flaws Pharmacy Intensity Score (PIS)



http://www.thelazarusreport.com

130 Hospitals 16 Key Metrics

5 Years ‐ History 106 Hospitals

Lazarus Report


Moses ConeUniversity

+40%

+18%

Community

FTEs per 100 Beds

Moses Cone Hospital Staffing Levels

Using the Lazarus Report Staffs its FTEs closely to

included community hospitals

Moses Cone operates well beyond the functions of a community hospital Level 2 trauma center Integrated delivery network Affiliation with schools of

pharmacy, nursing, and medicine

*FY15 projected


Moses ConeUniversity

‐7%

‐46%

Community

Pharmacist FTEs per 100 Beds

Moses Cone Hospital Pharmacist Staffing Levels

The Moses Cone Hospital staffs fewer pharmacists than surveyed community and teaching hospitals

MCH staffs 0.5% less than community hospitals and 5.8% less than university hospitals

*FY15 projected


Salary Expense per Admission The Moses Cone

Hospital Department of Pharmacy is managing its salary cost efficiently

In comparison to university hospitals, we have $129 less salary expense Only slightly more than

community hospitals Community hospitals

spent $44 less than MCH*FY15 projected

$250

$150

$200

$400

$100

0

$50

$300

$450

$350

+$44(+19%)

‐$129(‐32%)

CommunityMoses ConeUniversity


Salary Expense per FTE The Moses Cone Hospital Department of Pharmacy is managing its

salary costs efficiently In comparison to university and community hospital settings, MCH cost

per FTE is lower$77,000

$76,500

$76,000

$75,500

$75,000

$74,500

$74,000

$73,500

0

$76,600

$+3,474(+5%)

$‐2,274(‐3%)

CommunityMoses Cone

$73,126

University

$75,400


Salary Expense per FTE

University

‐46%

Moses Cone Community

+7%

Pharmacist FTEs per 100 Beds

University Moses Cone

27%

Community

Drug Expense


11%

10%

9%

8%

7%

6%

5%

4%

3%

2%

1%

0

12%

Community Hospitals

5.7%

Moses Cone

11.2%

University Hospitals

11%

Percent Residency Training Moses Cone Hospital’s

Department of Pharmacy is providing pharmacy resident education at the level of university-based hospital practices

Even as hospitals struggle, the preparation of tomorrow’s leaders continues to improve


Methodology – Vendor B

Collected data elements from various sources for FY 2014 and FY 2015 (September 30 year-end) Hours by job code and pay type Discharges by MS-DRG looking at both PIS and CMI Gross revenue and expenses by income statement category Area wage index (AWI) YES/NO questions Characteristics Normalizations

The discharges file provided was utilized to calculate necessary metrics for comparisons

Pharmacy intensity score (PIS) and case mix index (CMI)


Comparing Apples to Apples –Wait, What?

Vendor A: 50th Percentile(# of FTEs)/$$:

36.35 FTEs and $2.7M

Vendor B:50th Percentile(# of FTEs)/$$:

19.3 FTEs and $453K


Findings – Vendor B

Remember, we were NOT ranked with Vendor A – meaning we are >100% PIS Weighted Department Adjusted Discharges was favorable compared to

the 50% – we are seeing 15K more discharges compared to our peers At median for our hours worked per PIS Weighted Department Adjusted

Discharge – at 50% Total Expense AWI Adjusted per PIS Weighted Department Adjusted

Discharge was favorable compared to the 50% – actually below the 30% Labor Expense AWI Adjusted per PIS Weighted Department Adjusted

Discharge was favorable compared to the 50% – at 40% Drug Expense per PIS Weighted Department Adjusted Discharge was

favorable compared to the 50% – drug expense below 30%


Adjusted Patient Days How does an institution with less than 200 beds produce volume

numbers of hospitals twice its size? Example: XYZ Hospital #3 ranked

Adjusted Volume 13,582 at 160 ADC

Adjusted Patient days =

Institutions with higher proportion of outpatient revenue have falsely elevated patient day volumes

Institutions may have differing mark up on drugs provided as outpatient arbitrarily increasing revenues

If an institution does not manage its discharge process well (i.e., longer length of stay), its volume is increased and it looks like a higher performer!


Current Report

Vendor A: 50th Percentile - APD

(# of FTEs)/$$: 36.35 FTEs and $2.7M

Current Report – 2.0WHPU – Adjusted

Discharges – Better50th Percentile

15.54 FTE Opportunity


Knowledge WorkOur capital is knowledgeCollaborative protocols

Pharmacotherapy consults Pharmacotherapy consults originated

by a provider other than a pharmacist

Pharmacists provide direct patient care at Moses Cone Hospital

Collaborative protocols under the authority of the Pharmacy and Therapeutics Committee

The first protocol was written in 1977and was for heparin

Currently, there are 33 umbrella protocols containing 61 unique clinical guidelines

1

2

3

The term “Knowledge Work” was first coined by Peter Drucker

(1957). He suggested, “the most valuable asset of a 21st-century institution, whether business or

non-business, will be its knowledge workers and their

productivity.”


Selected Clinical Pharmacist Metrics

Weekly Date Ranges

Knowledge Work(Orders

Verified/week)~6% increase over prior 4

weeks

1/18/17-1/24/17 29,921

1/25/17-1/31/17 28,449

2/1/17-2/7/17 27,938

2/8/17-2/14/17 28,439

Direct patient care services on the units include: Daily rounds with and without physician teams, Management of drug consults to select and order

optimum doses according to renal function, indications,

Antibiotic stewardship, Patient education for all patients receiving

anticoagulants Resolving medication reconciliation problems,

developing new protocols and participation in multi-disciplinary committee work.

This 24/7 x 365 days/yr


Selected Clinical Pharmacist Metrics


Selected Clinical Pharmacist MetricsSub-category Metric (select examples – not inclusive)Direct Patient Care Number of patient counseling consults

Pharmacy consult service ordered per patient (excluding medication reconciliation and i-vents)

Number of clinical interventions by pharmacist per adjusted patient day

AntibioticStewardship

Total number of antimicrobial de-escalation events

TherapeuticMonitoring

Total number of pharmacy-recommended labs ordered

MedicationRegimenRecommended

Total number of pharmacy-discontinued drug recommendations

Total number of pharmacy-prevented adverse drug events

Total number of new pharmacy-initiated therapies


Reference: https://www.advisory.com/research/pharmacy‐executive‐forum/resources/2017/pharmacy‐dashboard‐and‐scorecard‐library?WT.mc_id=Email|Q218|RESEARCH+DOM|PEF|Resource|DashboardScorecards|76190|&elq_cid=1691480&x_id=003C000001SYDiSIAX

Selected Clinical Pharmacist MetricsSub-category Metric (select examples – not inclusive)Order Clarification Number of times pharmacy recommended dose

changes Number of times pharmacy optimized frequency Number of times pharmacy optimized

formulationPotential DrugInteraction

Total number of pharmacy-identified drug-drug interactions

Total number of pharmacy-identified drug-disease interactions

Medications: e.g. Warfarin, Heparin Daily labs Patient education documentation rate Therapeutic range (desired) written with orders Dosing nomogram utilized Baseline INR obtained prior to Warfarin therapy

(compliance with INR values prior to Warfarin administration)


Reference: https://www.advisory.com/research/pharmacy‐executive‐forum/resources/2017/pharmacy‐dashboard‐and‐scorecard‐library?WT.mc_id=Email|Q218|RESEARCH+DOM|PEF|Resource|DashboardScorecards|76190|&elq_cid=1691480&x_id=003C000001SYDiSIAX

Key TakeawaysStart…With a plan: Assemble a slide deck, add to it over time, add a rewards and recognition, FTE reapplications, etc.

Comparison of 2 vendors: Understand the differences in the methodology and explain the differences to those that would listen – and many did.

Disproportionate amount of outpatient revenue compared peers in BOTH vendors, even in the 2nd run of data from Vendor A – MAJOR DRIVER.

Allowed stratification in different ways, further isolating the true outliers: medication history program – MAJOR DRIVER.

I was able to educate my team and build consensus along the way; create appropriate cost centers to reapply FTEs where appropriate.


Key TakeawaysRecognize that if you expanded roles/emerging business lines/activities, that may not be included and questionnaires often are not sensitive or specific enough.

Question: “If you only devoted as much time to improving the department as you did trying to dispel the data.”

What we need is more pharmacy-led publishable research around VALUE-based benchmarking, productivity, and knowledge work – test new pharmacy models of care.

To balance, we also need responsible pharmacy leadership. We struggle with pruning our own areas and abandoning non-value added activities.

Demonstrate active participation: Actively participate in you own rescue


A Threat to Safe, High‐Quality Care

References: Dyrbye et al., 2017 and The Advisory Board


Clinical Well-Being and ResilienceResilience: The set of individual skills, behaviors, and attitudes that contribute to

personal physical, emotional, and social well-being, including the prevention of burnout.

These can include self-care strategies, safety nets for crises, organizational support, peer support, financial management, life-needs support and other forms of health promotion.

Well-being: Obtaining the psychological, social, and physical resources needed to meet a

particular psychological, social, and/or physical challenge. When individuals encounter an unbalanced situation, their individual well-

being suffers.

Reference: Bohman B, Dyrbye L, Sinsky C, et al. Physician Well‐Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience. NEJM Catalyst 2017 and Dodge, R., et al. The Challenge of Defining Wellbeing. International Journal of Wellbeing 2012;2(3): 222‐235.


Clinical Well-Being and Resilience -Research


Questions

Robert P. Granko, PharmD, MBA, [email protected]

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pharmacy practice: administration and management. 2nd ed. Bethesda, MD: American Society of Hospital Pharmacists; 1986:128‐37.

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Camp RC, Tweet AG. Benchmarking applied to health care. Jt Comm J Qual Improv. 1994; 20:229‐38. Charrois TL, Johnson JA, Blitz S et al. Relationship between number, timing, and type of pharmacist interventions and

patient outcomes. Am J Health‐Syst Pharm. 2005; 62:1798‐801. Enwere EN, Keating EA, Weber RJ. Balanced scorecards as a tool for developing patient‐centered pharmacy

services. Hosp Pharm. 2014;49(6):579‐84. Granko RP, Poppe LB, Savage SW, Daniels R, Smith EA, Leese P. Method to determine allocation of clinical

pharmacist resources. Am J Health Syst Pharm. 2012 Aug 15;69(16):1398‐404. doi: 10.2146/ajhp110510. PubMed PMID: 22855106.

Huntington N. Benchmarking in health system pharmacy: experience at Glen Falls Hospital. Am J Health‐Syst Pharm. 2000; 57(suppl 2):S21‐4.

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associated cost avoidance. Am J Health‐SystPharm. 2007; 64:63‐8. Lass G, Frandsen J. Hospital pharmacy data: hospital activity. Pharm Pract Manag Q. 2000; 19(4):1‐6. Ling JM, Mike LA, Rubin J et al. Documentation of pharmacist interventions in the emergency department. Am

J Health‐Syst Pharm. 2005; 62:1793‐7. McAllister JC. Collaborating with reengineering consultants: maintaining resources in the future. Am J

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Pharm. 2012;69(1):49‐54.

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56:516‐8.• Rough SS, Mcdaniel M, Rinehart JR. Effective use of workload and productivity monitoring tools in

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health‐system pharmacy, part 2. Am J Health SystPharm. 2010;67(5):380‐8.• Sayles TJ. Documentation of pharmacists’ interventions and associated cost savings. Am J Health‐Syst Pharm.

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prioritizing care - allocation of clinical pharmacist ... · (medication cost ... may be...

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