Tech-Check-Tech TCT Challenges and Opportunities Maryland Pharmacists Association

Tech-Check-Tech (TCT): Challenges and Opportunities Maryland Pharmacists Association Mid-Year Meeting Annapolis, Maryland February 18, 2018

Disclosures Drs. Cynthia Boyle, Kayla Mc. Feely, and Kristopher Rusinko have no relevant financial relationships with a commercial interest pertaining to the content of this presentation.

Objectives At the end of this presentation, the participant should be able to: 1. Describe at least 3 recent advances/initiatives for pharmacy technician education/training 2. Describe the Maryland Society of Health-System Pharmacy (MSHP) Acute Care TCT process and proposal highlights presented to the Maryland Board of Pharmacy

Objectives (continued) 3. Describe the successes and challenges of an optimized community pharmacy care model that enhances the role of qualified pharmacy technicians in order to reinvest pharmacists’ time to provide patient care services 4. Discuss steps, scope, and limitations for possible Tech -Check-Tech in Maryland

Format Introductions/Background TCT in Health-systems Optimizing Care in Community Pharmacy Facilitated Discussion- Challenges and Opportunities for TCT in Maryland (Audience Input for Maryland Stakeholders’ Conference)

Objective #1: Describe at least 3 recent advances/initiatives for pharmacy technician education/training. Cynthia J. Boyle, Pharm. D, FAPh. A Professor, University of Maryland School of Pharmacy MPh. A Past President

Poll the Participants State boards of pharmacy should require new pharmacy technicians to obtain national certification for registration or licensure (75/15/5/5) Bridging programs should be developed and offered to build competencies of pharmacy technicians who are currently in the workforce and would like to advance their skills (56/40/3/1) Planners should establish a coalition with broad representation for the recommendations from the PTSCC (77/23/0/0) Zellmer WA, Mc. Allister EB, Silvester JA, Vlasses PH. Toward uniform standards for pharmacy technicians: summary of the 2017 pharmacy technician stakeholder consensus conference. JAPh. A 57(2017)e 1 -e 14.

Education Perspective Quality in Pharmacy Technician education/training programs Program Accreditation Pharmacy Technician Accreditation Regulation of Pharmacy Technicians Role of academic institutions in education, training, and certification of Pharmacy Technicians Collaborations Mobley Smith MA, Boyle CJ, Keresztes JM, Liles J, Garrelts Mac. Lean L, Mc. Allister EB, Silvester J, Williams NT, Bradley-Baker LR. Advancing the Pharmacy Profession Together through Pharmacy Technician and Pharmacy Education Partnerships. Report of the 2013 -14 Professional Affairs Standing Committee. Am J Pharm Educ. 2014; 78(10): Article S 22.

“The ability of pharmacists to successfully fulfill patient care provider roles depends on how well pharmacy technicians are prepared to function in their roles a pharmacy supportive personnel. ”

2017 PTCB-ASHP-ACPE Consensus Conferences All pharmacy sectors were engaged including preconference poll of JCPP member organizations. State variability in regulations poses risks for patients and the profession. Task analysis should be basis for accredited technician education, technician certification, and state regulations. Participants recognized generalist knowledge/skills/abilities regardless of practice and need for additional programs beyond entry-level (advanced).

Pharmacy Technican News PTCB- founded in 1995 by APh. A, ASHP, Illinois Council of Health-System Pharmacists, and Michigan Pharmacists Association, and joined by NABP in 2001. PTCB advocates for a single national standard for pharmacy technician certification, recognized and supported by the profession. PTCB advances medication safety by certifying technicians who are qualified to support pharmacists and patient care teams in all practice settings. New PTCB Executive Director William Schimmel www. ptcb. org

Jan. 11, 2018 PTCB News Release: Exam and Education Changes Exam Content Domains (9 to 4) from 2016 Job Analysis, Entry Credential Med Safety/Patient Care Focus Education- PTCB or equivalent experience Effective Jan. 1, 2020 90 -Day Comment Period Staff Sgt Mary Johnson PTCB CPh. T of the Year 2017

Active Learning The statement which best describes the outcomes of the Pharmacy Technician Stakeholders Consensus Conference (PTSCC) is: 1. By 2020, all pharmacy technicians should be licensed. 2. By 2020, all pharmacy technicians may qualify for certification by PTCB courses or experience. 3. By 2020, all states should enact comparable technician regulations. 4. By 2020, all schools/colleges should offer technician education/training.

Tech-Check-Tech (TCT) MSHP Workgroup Kristopher Rusinko Pharm. D. , MBA, M. Ed. Director of Operations Johns Hopkins Health System

Objective #2 Describe the Maryland Society of Health-System Pharmacy (MSHP) Acute Care Tech-Check-Tech (TCT) process and proposal highlights presented to the Maryland Board of Pharmacy

TCT - Background • Specially trained and validated pharmacy technicians (VPT) verify accuracy of medications filled by another technician • No clinical judgment required • Studies demonstrate technicians are at least as accurate as pharmacists • Barcode scanning technology provides a safeguard against dispensing the wrong medication • Reallocation of pharmacist time to patient care tasks

Board Approval - Institutional Setting 23 states allow TCT

Board Approval - Community Setting 7 states allow TCT

Workgroup Process Overview University of Wisconsin Health and University of Iowa Health Conference Calls UW Health/ Pharmacy Examination Board Toolkit Conversations with other states (student project) Retreats and small work groups to update documents and discuss roles of VPTs

Roles of VPT Proposed to Maryland BOP Bar code scanning required Automated Dispensing Cabinet (ADC) filling Batch dose preparations Code box/tray filling Unit dose prep from bulk bottles

Handout Review Appendix A – Lit Summary Appendix B – Cover Letter Variance Request Appendix C – Variance Request form Appendix D – Sample Policy Appendix E/F – Additional samples Appendix G – Practical Training Checklist Appendix H – Competency Assessment Checklist Appendix I – TCT Overview for Technicians Appendix J – TCT Training and Self Learning Packet Appendix K – Written Examination Appendix L – Skill Validation Process Guidance Appendix M – Initial Validation Error Log Form Appendix N – Quality Assurance Process Guidance

Handout Review (cont. ) Appendix O – Quality Assurance Error Log Sheet Appendix P – Variance Report to Board Appendix Q - Artificial Error Log Appendix R – Examples of Artificial Errors Appendix S – Cart Fill Artificial Error Examples Appendix T – Tech Initial Validation Log Appendix U – QA Monitor Report to Board Appendix V – TCT Implementation Checklist

Current Situation Pilot sites identified Proposed to MDBOP 9/20/17 MDBOP created a work group of its members to review Setting where applicable Training and requirements Activities authorized Tracking and reporting

Active Learning Which of the following have been proposed as items to be checked in an acute care setting TCT Program: (1) Product verification prior to restocking Automated Dispensing Cabinet (ADC) (2) Batch dosing preparation for loading into ADCs (3) Code tray/box filling (4) Drawing up oral doses from manufacturer bulk bottles of liquid medications (5) All of the above

Objective #3: Describe the successes and challenges of an optimized care model in the community pharmacy setting Kayla M. Mc. Feely, Pharm. D Executive Fellow National Association of Chain Drug Stores

Innovation in Pharmacy “Change is a common thread that runs through all businesses regardless of size, industry and age. Our world is changing fast and organizations must change quickly, too. Organizations that handle change well thrive, whilst those that do not may struggle to survive. ”

Optimizing Care Enhances the role of qualified pharmacy technicians in order to reinvest pharmacists’ time to provide patient care services Improve patient access and healthcare outcomes Utilize full potential of clinical expertise of pharmacists and the skills of technicians Iowa, Wisconsin, Tennessee

NACDS Optimizing Care Projects: Chain and Independent Pharmacy Participation

Current Status 1. Iowa Transition to dissemination phase Sharing their experiences and insights Webinar series – upcoming 2. Wisconsin Concluding data collection Data analyses upcoming 3. Tennessee Recruitment Baseline data collection 4. Qualitative analyses – all 3 projects

Optimizing Care Myths De-bunked Courtesy of the Tennessee Pharmacists Association Court e sy an d Pro perty ists of the rmac a Assoc TN Ph a iatithe rmac rty of onn ists e p d Pro ssociatio y an A urtes Co

Patient Safety Total Wrong Drug Wrong Strength Safety Cap Error Wrong # Other Error Total Errors Accuracy Rate RPh-Checked (Baseline) 5, 565 1 0 8 2 4 15 99. 73%* Technician-Checked (Pilot ) 5, 950 1 2 19 3 8 33 99. 445%* *not significantly different Iowa Optimizing Care Pilot – Phase 1

Challenges Pre-implementation Phase Board of pharmacy approval Recruitment of pharmacies IT remodeling Separate distinction for checking technicians • Workflow redesign plan • Perceptions and myths • • Implementation Phase • Technician verification process – time consuming • Want to verify more technicians – coverage • Staff turnover • Takes time to adapt to new responsibilities • Perceptions and myths

Successes: Time Reinvestment Decrease Increase • RPh time spent dispensing 67. 3% to 48. 58% (p=0. 004) • RPh time spent patient-care activities 15. 9% to 35. 08% (p=0. 002) Iowa Optimizing Care Pilot – Phase 1

Successes: Areas of Impact Increased number of services provided Identifying drug therapy problems Immunizations, and non-immunization injections MTM services – disease management, adherence monitoring, med sync, compliance packaging Potential for further advancements TN pilot – CPA engagement Preventative services, point of care testing, more

Successes: Qualitative Data “After performing double checks of the verification technician's initial checks, the results for me have been abundantly clear: She does just as good of job at checking prescriptions as me or any pharmacist does. ” “By allowing me to thoroughly check a patient's medication list and perform drug utilization reviews prior to any medication being filled in the pharmacy, I am able to provide better outcomes to patients while spending more time with each individual patient. ” “Patients don't have to wait to be counseled or receive immunizations. Patients receive the care they deserve while spending less time sitting in the pharmacy waiting area. ” “Overall, things are going “Instead of having baskets really well and I have pile up every time I was noticed a significant reduction in my stress level busy performing other “Freeing up our and my co-workers' stress. ” tasks, I now know that my verification technician will pharmacists' time has get it done. ” allowed us to grow clinically. ”

Final Thoughts Pharmacy technicians may be able to perform final product verification at least as accurately as pharmacists Pharmacists may spend more time providing clinical services when the optimizing care model is utilized Value of RPh discretion and clinical judgement preserved Essential: quality assurance/improvement, and patient safety

Acknowledgements Iowa Pharmacy Association Pharmacy Society of Wisconsin Tennessee Pharmacists Association 1 st Pharmacy Services Aurora Boscobel Caves Comprehensive Wellness Community Pharmacy Fnd Crawford’s Costco East TN Discount Froedtert Hartig Drug Hayat Hy-Vee Kroger Main at Locust Mc. Kesson Medicap Mercy Family Pharmacy Nu. Cara Pulaski Publix Perkin’s Shopko Surgoinsville Target Telligen Terry’s Thrifty White Towncrest UW Health Walgreens Wester Drug

Active Learning True or False: An optimizing care model has the potential to advance patient care in community pharmacies.

Objective #4: Discuss steps, scope, and limitations for possible Tech-Check-Tech in Maryland. Input for Maryland Stakeholders’ Conference Open Discussion- All Participants

Emily Jerry Foundation https: //emilyjerryfoundation. org/