Jerry Fahrni

We’re asking the wrong questions

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Jerry Fahrni

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thoughtful_monkeyA couple of weeks ago I spent the morning with a friend of mine. He also happens to be a pharmacist and the director of a pharmacy IT group for a medium-sized healthcare system. As one might imagine we have similar interests, which means we spend most of our time together talking about pharmacy; where we’ve been, where we’re going, how to make it better, and so on. We both think that pharmacy is moving at a glacial pace when it comes to making important changes and any real change will likely occur long after we’re both retired.

One thing that occurred to us during the conversation was that we always seem to ask the same questions, which always results in the same answers.

  • How do make a process faster [to free up pharmacist’s time]?
  • How do we make a process more efficient [to free up pharmacist’s time]?
  • How do we make a process better [to free up pharmacist’s time]?
  • Etcetera

As we sat around talking through these questions for the umpteenth time he said something that I thought was very telling. He said that “no one in pharmacy has any vision”. He’s right. Lots of people talk about being innovative, but no one talks about having vision. True innovation is rare, extremely rare. People toss the word around all the time, but most of the “innovation” I see is little more than an incremental improvement on something that already existed. Basically the changes come from answers to the questions above. Vision allows you to see into the future and begin pulling pieces of the puzzle together in a way that will allow you to get there. People with vision are rare. I’ve only met a couple of pharmacy visionaries during my entire career of 15 years.

So what questions should we be asking? Well sit back and I’ll tell you.

  • Question 1: Why do we do things this way? – I bet the answers to this question will surprise people. Most processes in pharmacies are rooted in ancient dogma or regularly CYA. I’ve asked this question many, many times during my career, and the most common response is “I’m not sure, we’ve always done it that way.” That’s a terrible answer! Anyone giving that answer should be placed in the corner and forced to wear a pharmacy dunce cap, or a T-shirt that says “Don’t ask me, I have no idea. I just work here”
  • Question 2: What should this process look like to keep us out of the loop? – Something truly innovative will ultimately take you, the human, out of the equation. Example: BCMA requires pharmacy personnel to scan medications before reaching the floor where nurses scan the medication prior to giving it to the patient. Makes sense to me for several reasons, but ultimately a drug may be scanned two or three times before reaching a patient. In an ideal situation you would never scan a medication because some system would know what you have in your hand during both the dispensing and administration phase. Only incorrect attempts would be acknowledged. Scanning 100 items 300 times looking for a single error is silly, but that’s how we’ve developed the system. Crud, I think an IV hood should analyze everything you do inside the sterile area and let you know when you’ve done something wrong. Look at all the work being done to make the IV room safer. They’re all wrong. Here’s another thought for you: how many humans do you think touch and/or move a drug before it ultimately reaches the patient? Three? Four? Five? Again, that’s just silly.
  • Question 3: How do we get there? –  We’ll have to work backward toward a solution that will ultimately change how we do things. Moving forward with the same process only improves the process, and the process you’re working so diligently to improve may be the wrong one. Chew on that.

Many times I’ve heard people tell me something “will never work” for one reason or another. I hate it when people say that. Reinventing the wheel over and over again does nothing more than give you a better wheel. I want my own personalized transporter sitting in my garage. Star Trek had the right idea, and they thought of the idea in 1966. Pharmacy has yet to have that revolutionary vision we so desperately need, and until we have it we’re stuck in neutral. Just sayin’.

Comments

3 responses to “We’re asking the wrong questions”

  1. The Cynical Pharmacist

    Not to seem argumentative, but the first question should be – why do we need to free up pharmacists’ time? What will pharmacists do with that extra time, and will it lead to less pharmacists being needed?

    Here’s another thought for you: how many humans do you think touch and/or move a drug before it ultimately reaches the patient? Three? Four? Five? Again, that’s just silly.

    Personally, I prefer more people to look at a drug before it reaches a patient. In retail, the drug goes directly from the pharmacy to the patient. If a mistake was made, there are less people to catch it. A second set of eyes may have caught the mistake.

    One of the things that appeals to me in the hospital setting is that there’s at least one intermediary between me and the patient. The nurse reviews the medication before it’s given to the patient. I can’t tell you how many times I’ve thankfully seen nurses catch pharmacy mistakes. Plus, there’s the tech who made it, the tech who delivered it, and perhaps someone on the floor looking at it. Who wouldn’t want all those people on their side helping prevent a possible medication error?

    Just saying..

  2. Jerry Fahrni

    TCP –

    I think you missed the point of the post. I think there are things that pharmacists can do well, when they have the time. We’re pretty good a drug therapy optimization; we’re pretty good at PK; we do a fairly good job of renal dose adjustment; and so on. You and I both know that if we stay tied to dispensing we’re professional walking dead men. Cost will eventually do us in.

    I’ve been involved in a couple of situations where my time away from dispensing made a direct impact. One was in a hospital where pharmacy managed most of the dialysis patients with anemia (pretty much all the dialysis patients had some form of anemia). Data collected from the anemia management service showed equivalent outcomes, i.e. numbers, and a huge cost savings. I’m not talking soft dollars, I’m talking actual reduction in the amount of epo used. The pharmacy service saved enough on epo to pay for a FTE pharmacist to do nothing but manage the service. Not glamorous, but worthwhile. …I actually hated the service, but some of the pharmacists loved it. Different strokes, and all that jazz. The pharmacists that like it enjoyed the time out of the pharmacy. The second was a hospital I worked in that had pharmacy take care of all the TPN patients; electrolyte correction, TPN formulation, BS management, etc. Again, I didn’t like doing it, but it got me out of the pharmacy and the IV room pharmacist loved it. Why? Because the TPN patients managed by pharmacy always had the formulations correct by the time it hit the IV room, the paper work was error free and the TPN order arrived in the IV room before the 3:00PM deadline. Was it better patient care? Heck if I know. Did it save the hospital money? Doubtful. But it did make life easier for our entire IV room staff; pharmacist, technician and runners. In my opinion that was time well spent out of the dispensing role.

    And as far as the “double check” goes, I’m not bashing it. What I’m saying is that in a hospital setting a drug is shuffled from place to place by many hands. Each shuffle is an opportunity for a mistake; checking the order in from the whilesaler, putting the order away, pulling the order for ADU or cart fill, filling the ADU or cart, nurse accessing for med pass, nurse admins to patient. That’s a lot of places for a mistake to occur. Should someone check to make sure that something was pulled or made correctly? Sure because in our current system that’s the best we can do. My point was that in our infinite wisdom to improve things all we do is throw people at the problem. We, the people, are notoriously bad at repetitive tasks. You know, checking bias, tired eyes, distracted thoughts, and so on. Have you ever let something past you that was wrong? Sure you have. I have. Too many times. Every pharmacist has. My post may have been a bit unclear, but my point is that the profession should find something besides bodies to throw at a problem, and our current options aren’t the answer.

    As always, appreciate your thoughts.
    -Jerry

  3. RxINFORMATICA

    I understand the value of a double check, but when we talk about “checking” in a traditional dispensing role, machines do a much better job because they aren’t subject to fatigue or confirmation bias. Humans are necessary and concepts like tech check tech + BCMA really free up pharmacist time. My understanding of the post is we need to start thinking of ways to be leaner or more efficient.

    We should be finding better ways to leverage the fact that we work in a data rich environment. Why do we need to free up pharmacists’ time? Because every bit of waste in the pharmacist workflow is an opportunity cost for improved patient outcomes.

    In my opinion, our profession’s culture of resistance to change is holding us back. I wonder if more pharmacists got trained in Lean or Six Sigma, would it make an impact? This goes back to the concept of “you don’t know what you don’t know.”

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