1. Management Dilemmas: Integrating New and Established Practices South Carolina Society of Health System Pharmacists Spring Symposium, 2008 Joel Melroy, PharmD, MS Manager, Ashley River Tower Pharmacy Services Medical University of South Carolina

2. Ashley River Tower

3. 156 bed service line hospital Heart & Vascular Service Line Digestive Diseases Service Line Patient Tower: acute care + ICUs Diagnostic & Treatment: ORs, Cath labs, IR Chest Pain Center Clinics Projected 60% capacity – budgeted staffing

4. Ashley River Tower Inpatient Pharmacy Clinical and distributive services Inpatient units, procedure areas, clinics Automated Dispensing Machine (ADM) Service Operating Room (OR) Pharmacy – Carole Russell Pre-op, OR, PACU Retail Pharmacy – Heather Kokko Outpatient & employee prescriptions

5. Overview Planning Resources Operations Clinical Practice One week prior to opening One week after opening One month after opening

6. Key Observations A large project such as opening a new hospital requires teamwork This feat could not have been accomplished without teamwork from the pharmacy director, management team, and staff

7. Planning BoP, DHEC, and DEA licensing and revision – 12/07 Facilities Distribution Plan Point of Care medication administration Hybrid cartfill-cabinet model Courier service ADM cabinets, configurations, inventory Technology Implementation BCMA, Smart Pumps, CPOE Inventory Accounts, contracts Dilemmas: New standards, unplanned facility surprises Robot/cartfill in a separate facility Dependent on another department to provide courier service BCMA, Smart Pump rollout Too much vs. not enough

8. Facility Surprises…

9. Resources Personnel Attract and select the best people Train sufficiently Share resources, if necessary Dilemma: Midnight Pharmacists Equipment Purchase redundant equipment? Support for new automation/technology Dilemma: Medication Transfer Carts

10. Operations TaskMUHART UD prepXX IV batchesXX ChemotherapyXX ADMXX 24-hr cartfillX (completed at MUH) TPNsX (completed at MUH)

11. Operations Daily order: delivered to ART ADM service ART staff Administrative/Superuser support provided by MUH Courier service Distribution Center, Compounding, AIP, ART Up to 8 runs per day Dilemmas: Incorporating workflow of two separate operations, ADM training, courier

12. Clinical Practice Established model: specialist Clinical pharmacists perform order entry functions and specialists round with teams Desired model: integrated w. coordinator Clinical pharmacists expand their roles and specialists coordinate activities, initiatives Dilemma: changing practice models with practitioners with established roles

13. One Week Prior… Limited access to hospital Hospital DHEC licensing Successful BoP inspection, DEA Licensed on 1/30 (Wednesday) 1 st drug order: 1/31 Stocked 3 pharmacies + 50 ADMs Completion: 2/3 Opened: 2/4 We didnt have time for dilemmas!

14. One Week Prior… Issues Completing the initial drug order Used purchasing data from MUH Did not order non-formulary medications Planned to utilize MUH inpatient pharmacy for medications not ordered initially (tube system) Medication security/transport ~50 to 90 patients expected to move to ART Medication transport bags and labels Filling ADMs + inability to access hospital Midnight pharmacists not fully trained Smart Pump rollout – all IV medications to be changed out at arrival to ART

15. Opening Incident Command Team – Disaster Medication Staging – MUH Supply Team Leader – ART Daily meetings from Thursday until Sunday Moved 59 total patients with 7 admissions in 5.5 hours Pharmacists located on floors and in central pharmacy Pharmacy team – extremely responsive to changing needs & stress on the floors

16. One Week After… Inventory stabilizing Decentralized pharmacists on floors Daily staff meetings Issues: Courier service not consistent Medications needed for clinics IT issues (fax server, computers) Central pharmacy organizational patterns Distribution/paperwork Staffing Technician/pharmacist training

17. One Month After… Weekly staff meetings Ongoing training Courier/distribution becoming smoother Continuing issues Staffing/training Gaining resources for increasing staff levels Some IT issues (fax machines) Changing to an integrated practice model Workload increasing – census above the projected 60% level

18. Lessons Learned It takes many dedicated people working as a team to accomplish such a large feat Some change can occur in a minute and other change takes more time Listen to your staff and meet frequently – communicate Listen and respond to nurse/physician needs while remaining calm Be action-oriented and responsive Set up as many systems as possible prior to opening (e.g., distribution, courier, clinic meds) Complex problems require complex solutions…dont settle for the quick fix Be visible to your staff, nursing staff, and physician staff Be involved with multidisciplinary operations committees and other teams before and after the move – you will gain insight on system issues and staffing patterns Be flexible and open-minded Be surrounded by high performers

19. Staff Kristen Baker Nicki Balchin Courtney Bath Sharon Fahey Carrie Flippen Charles Garred Tom Gnau Phil Grech Chanda Harrison Mary Jo Jack Shantee Jacques Charlotte Johnson Bruce Keck Kristen Baker Nicki Balchin Courtney Bath Sharon Fahey Carrie Flippen Charles Garred Tom Gnau Phil Grech Chanda Harrison Mary Jo Jack Shantee Jacques Charlotte Johnson Bruce Keck Devin Matthews Crystal McKinley Kathryn Noyes Johnte Porter Emily Poston Becky Schneider Trish Schuler Dianna Sellers Kendra Seward Sam Solomon Walt Uber James Walker Joyce Warren Marina Williams

20. Management Team Paul Bush Carole Russell Chris Fortier Heather Kokko Joe Mazur Matt Maughan Kelli Garrison

21. Questions?