With the demands for clinical pharmacy services increasing and personnel resources continuing to be stretched, we wanted to find a realistic and comprehensive metric to help illustrate pharmacy workflow to ensure that our pharmacists are working efficiently and safely. We performed peer surveys and literature searches to identify commonly used productivity metrics, especially those focusing on inpatient pharmacy and order verification rates. The results demonstrated a wide variability in collected and reported data, and ultimately, a lack of any true “gold-standard” or “benchmark” metric.
As a result, we led a lean process improvement initiative to assess the clinical order verification processes at Baystate Medical Center (BMC) and to identify an internal benchmark for safe order verification rates. Specific objectives included the development of a benchmark for BMC clinical order review to define accountability (quality of order review and documentation) as well as identification and assessment of inefficiencies (ie, “nonproductive” time) in daily practices to streamline and optimize workflow.
A multidisciplinary verification process improvement team (VPIT) consisting of the medication safety coordinator, 11 clinical pharmacists, 3 pharmacy technicians, and 3 nurses was created. Members of VPIT directly observed pharmacist workflow and verification processes within the inpatient pharmacy. They sought to understand the steps of order verification, as well as to quantify and identify pharmacist interruptions, workflow inefficiencies, and order verification times to define an order verification rate benchmark. Multidisciplinary team meetings employed value stream mapping exercises to delineate the order verification process (Figure) and to identify waste. Value stream mapping is a lean technique used to assess and analyze the flow of materials and information.
The VPIT calculated a rate of 35 orders per hour per pharmacist as the maximum rate that allowed safe and accurate clinical review of medication orders at BMC. This was calculated through pharmacist observation of an average cycle time (time to verify one medication order) of 1.7 minutes with interruptions. Identified inefficiencies were associated mainly with breaches in workflow, including difficulties in medication information retrieval and nonclinical disruptions during the verification process. Changes were implemented to help mitigate these inefficiencies and achieve and sustain a safer order verification rate in the absence of additional pharmacy staff. Interventions included the development of pharmacist workstations with dual-screen displays, pharmacist and technician workflow redesigns, and a phone call tree system to reduce interruptions of pharmacists with nonclinical calls (ie, automated dispensing cabinet drawer jams).
Internally, the order verification metric has been used to assist in planning for BMC’s pharmacy practice model redesign and has established minimum staffing levels. The order verification rate benchmark also has been helpful when strategizing for the addition of clinical initiatives to pharmacist workflows and has provided an opportunity for pharmacy managers to discuss productivity with individual pharmacists. Now that BMC has reduced inefficiencies in its workflows and added clinical activities to them, plans are to replicate this activity with the current model to accurately reflect health system productivity.
a At the time of the project, Dr. Szerszen was a postgraduate year 1 resident, but she has since graduated and is now a clinical pharmacist at UMass Medical Center, in Worcester, Massachusetts.