Under pressure: Performance metrics in chains may affect safety
June 01, 2015
pressure that many chain pharmacists feel
“It’s all about numbers. That’s all they care about. You’re there and on your feet for 8 hours, and you’re at the mercy of the volume.”
The speaker was Bill Bradshaw, BSPharm, a semiretired former Walgreens pharmacist from Arlington, TX. He was describing the pressure that many chain pharmacists feel as they try to meet prescription fill-time goals while fielding phone calls, managing auxiliary staff, and keeping up with immunizations and customers’ medication therapy needs.
The yardsticks companies use to evaluate how well pharmacists manage these complex professional duties are known collectively as “performance metrics.” It is a phrase that pops up frequently in pharmacists’ blogs, tweets and other online forums—and not usually in a positive way. A common thread is that use of metrics to help speed prescription flow often runs counter to good pharmacy practice and heightens the danger of increased medication error rates.
“It’s time pharmacists are protected from this metrics system,” wrote Katrin Olavessen-Holt, commenting on a Pharmacy Today Facebook posting of a March 3, 2015, CBS Sacramento article headlined “Call Kurtis: Pharmacists Concerned Employer Pressure Leads to Prescription Errors.”
“Speed and money over safety. Never a good thing!!,” added Carrie Wellman Arbuckle. The article describes the potential downside of performance metrics in California. The Today posting drew more than 325 “likes” from Facebook followers.
Major chains: Different view
The three major pharmacy chains have a different view of the metrics they use to evaluate pharmacy performance. And they cite their efforts to smooth pharmacy workflow and ensure customer satisfaction and safety.
CVS/pharmacy spokesman Michael DeAngelis responded to Today ’s request for comment with a statement saying that CVS, like other companies, “measures the quality and effectiveness of the services we provide to ensure we are meeting our customers’ expectations and helping them to achieve the best possible outcomes. Our systems are designed to help our pharmacists manage and prioritize their work to best serve their patients.”
Jim Cohn, a Walgreens spokesman, said in an e-mail that “quality, safety, and accuracy are our top priorities, and we make it clear to our pharmacists that they should never work beyond what they believe is safe, in their professional judgment.”
At Rite Aid, spokeswoman Ashley Flower stated that the chain was “highly committed to patient safety and care,” adding, “We have a strong safety record because of our ongoing education and training for pharmacy associates as well as our continued investment in technology.” Rite Aid, she said, uses “various metrics to ensure we are consistently delivering a superior customer experience and helping those we serve achieve the best possible health outcomes.”
The safety equation
While the chains do invest heavily in new technology systems, workflow design and training programs to meet the expanding demands on pharmacists’ time, there is always the risk that ever-increasing prescription volume and bottom-line considerations may tilt the safety equation to the negative side. Moreover, policies created at the top to ensure that pharmacists are well equipped to handle both dispensing and patient care responsibilities can encounter obstacles as they filter down to supervisors, who themselves may be under pressure to perform.
David Nau, BSPharm, MS, PhD, president of Pharmacy Quality Solutions Inc., noted that many studies in the past had shown an association between volume of work and medication error rates. “One thing that makes a difference,” he said, “is that the complexity of work, or the workload issue, is intertwined with staffing and processes. Part of the issue of reducing distractions of pharmacists is finding the right balance of workload and the pace of work.”
Some pharmacists maintain, however, that the balance can be thrown off kilter by technician staffing that fails to account for the high number of prescriptions that pharmacies are called on to dispense. “They keep cutting tech staff hours, regardless of the volume,” said Steve Ariens, BSPharm, national public relations director for the Pharmacy Alliance, a pharmacists’ advocacy group. He likened it to the slave galley rowing scene in the 1959 movie classic Ben-Hur. “Rowing faster and faster: that’s pharmacy,” he said.
Bill Bradshaw said it was “practically impossible to do your job the way it was supposed to be done with the help that they gave you.” At one Fort Worth, TX, Walgreens where he worked, “it was very intense,” he said. A doctor he consulted told him that he was suffering from post-traumatic stress disorder. He finally left the pharmacy after about 3.5 years. During that time, he said, “That one store had five pharmacy managers. They just couldn’t handle it.”
‘From green to yellow to red’
One widely used performance metric tracks prescription dispensing time from customer drop-off to pick-up bin. The limit is often set at 15 minutes. David Stanley, BSPharm, a California pharmacist who worked for both Rite Aid and Walgreens, told Today that both chains used computer clocks to monitor the time. The clocks “would slowly turn from green to yellow to red,” he said, “depending on how quickly prescriptions were getting out the door.”
Stanley added that he saw “nothing wrong” with metrics in general, particularly if used to evaluate quality, but “the problem I’ve run into is that they choose their metrics poorly. And they lose sight of the goal, which is happy customers and pharmacy practice the way it is supposed to be practiced.”
He described a prescription label policy that Rite Aid had in effect when he worked there several years ago. “We were told never to print more than five labels ahead,” he said, but “we had our own way of doing things, which was to print labels for as many prescriptions as we could and get them as close to being filled as we could. That way, when it was slow, you could work on the label pile and basically get a few out the door in between customers. It was a great system,” he said. “When we started following their directive, it actually slowed us down and it worked against their larger goal of happy customers and quality prescriptions.”
“They didn’t want to hear it,” he said.
Lawsuits against chains
Some pharmacists have brought lawsuits against chains. Joseph Zorek, BSPharm, for instance, has a current suit against CVS Health. He told Today that performance policies and “intimidation” he encountered as pharmacist-in-charge at a Harrisburg, PA, CVS pharmacy, led to various physical ailments and disability—the basis for his legal action.
Zorek described one metric CVS used to evaluate performance. “They wanted us to sign up all patients to ReadyFill,” the chain’s automatic prescription-filling program. He said his patient base consisted of a higher-than-average number of senior citizens, who “felt much more comfortable being in charge of their own prescriptions. As a result, my metric for signing up people was low.”
Zorek added that he felt he could “play ball” with most of the other requirements. “They had a 15-minute constraint” for measuring prescription fulfillment time. “That was fine,” he said, “but normally Murphy’s Law would set in, and something would go wrong.” Describing a hectic pharmacy scene in which techs were often called away to take over busy cash registers and pharmacists were forced to handle calls on 10 different telephone lines, he said, “Your mind was in too many places. The error rate started to go up. We were making stupid little mistakes: using the son instead of the father, wrong address, improper doctor. ”
Still, Zorek said, he “enjoyed the pace and working with people”—that is, until the company began cutting technician hours. His wife, Paula Zorek, who also worked at CVS, as a technician and technician trainer, said that in 2011, every store was losing technician hours. “They upgraded the computer software,” she said, “and they thought they could do more with less. It didn’t work out that way.”
2012 ISMP/APhA survey
Anecdotal complaints about the use of metrics and pharmacy workload have circulated for years. In 2012, the Institute for Safe Medication Practices (ISMP) launched a survey in collaboration with APhA. One aim was to assess the impact of prescription fill-time guarantees on pharmacy safety. A total of 673 pharmacists responded, most of them from chain drug and grocery/mass merchant pharmacies. A major finding was that 83% of those working at pharmacies with advertised time guarantees believed that the guarantees were contributing to dispensing errors.
In response, the National Association of Boards of Pharmacy (NABP) issued a statement resolving that NABP “assist the state boards of pharmacy to regulate, restrict, or prohibit the use in pharmacies of performance metrics or quotas that are proven to cause distractions and unsafe environments for pharmacists and technicians.”
Fewer errors: One solution
Are there solutions for reducing the potential safety hazards of performance metrics and prescription time-filling guarantees? Nau, whose company supports health plans, PBMs, and community pharmacies in their efforts to measure and improve medication use quality through its EQuIPP program, said that “we actually find that when pharmacies synchronize the refills of patients on chronic medications, it helps to smooth out the workflow and balance the ebb and flow of volume throughout the day.”
That should help lead to fewer errors, he noted. He also said that as “pharmacists do more to be proactively engaged in managing their patients’ regimens, it will help to balance the workload. So when issues arise, that communication will help to identify potential issues before they become a major event for the patient.”