As consultant pharmacists take on new responsibilities during regular visits to nursing homes, new ways of measuring their productivity are emerging. Here's how some managers are doing it.

L. Michael Posey

Determining a reasonable workload has never been simple for consultant pharmacists, with variations in travel times, different types of nursing homes and residents, and idiosyncratic differences among people. But as consultant pharmacists develop increased levels of activity in areas such as in-service programs, clinical research, therapeutic substitution, and patient assessment, the task has become much more complicated.

This article describes how some managers are approaching the difficult chore of measuring the productivity of their consultant pharmacists. Here's how they are adapting the useful frameworks of today into the yardsticks of tomorrow.

Seven Categories of Work

"Most of my consultant pharmacists do about 60 beds per day," says Dana Saffel, executive director of United Pharmacy Services in Atlanta. "But that's a full day for some of them, while others seem to find ways to do a dozen other things while they're in the home. While I don't use such productivity data in personnel reviews or salary adjustments, I constantly look for ways to recognize those pharmacists who are doing the extra things that make our residents better, our clients happier, and our business larger."

Fred Wendt, regional director of consulting services at Dallas' Pharmacy Corporation of America office, agrees: "Productivity measurement has a place in management, but it's not as a punishment. It's to show the person where their time is being spent. Even pharmacists on my staff who were initially resistant to data collection about where they spent their time are now strong supporters of the program. They want to see the reports each month."

Wendt divides pharmacists' time up into seven common activities:

1. Drug regimen review: actual time spent reviewing charts
2. In-service education programs, including development and delivery
3. Travel: an integral part of consultant pharmacists' jobs
4. Meetings: time spent in discussions with facility or pharmacy personnel
5. Medication room and cart audits: these functions are increasingly handled by technicians
6. Maintenance: all the odd things that have to be done, such as setting up computer programs or printing reports
7. Miscellaneous: Everything else, including telephone time, destroying drugs, performing DUEs

Data from each consultant pharmacist in the region are then compiled and graphs (Figure 1) are compiled for each person. By comparing their percentages with those of all pharmacists in the region, the pharmacists learn from their peers the areas in which they might be able to make improvements in time management.

Figure 1. Examples of Charts on Time Management Provided Monthly to PCA Consultant Pharmacists in the Company's Southwestern Region.

Saffel adds an important principle to consider: "Productivity is great-if the pharmacist is producing a quality product. But I'll take accuracy over a reasonable speed any day. Demming has influenced my opinions such that I tend to look for the system problem rather than focusing too much attention on the individual. In my experience, good attitudes lead to great productivity-and systems can poison attitudes. Management's job is to find these obstacles and remove them when possible."

Making Productivity a Clinical Issue

At Omnicare, consultant pharmacist report card indicators bring a clinical perspective to the job. Mark E. Lehman, Director of Clinical Services, tells TCP that formulary and disease management indicators provide individual consultants with information on the effectiveness of their activities.

Process indicators are included on the formulary management side of the report card. These include drug-regimen review data, often broken down into various diseases that are being tracked closely. More general indicators include calculations such as these:

• Percentage of market share of selected agents moved via therapeutic interchange programs
• Percentage of unacceptable drugs being used (from clinical literature and governmental lists)
• Percentages of preferred drugs being used (per Omnicare's Geriatric Pharmaceutical Care Guidelines)

But the heart of the effort, Lehman notes, lies in the outcomes indicators-the link between consultants' activities and better quality of life for residents. On this side of the ledger are data such as the following:

• Percentage of residents/home/ year who are immunized with influenza vaccine
• Optimization of pharmacotherapy in disease management programs-either already rolled out or being planned-in the areas of heart failure, depression, atrial fibrillation, and osteroporosis
• ACE index, a calculation of the amount of ACE inhibitors used in a home as a marker for optimizing the pharmacotherapy of heart failure, per the practice guidelines issues by the Agency for Health Care Policy and Research

"We are focused on outcomes as well as the consulting process," Lehman says. "For instance, the osteoporosis disease management program will focus not only on identifying and treating osteoporosis, but also on prevention of falls-because what is really important is to keep residents from breaking hips, in addition to which medication they're on."

Productivity Data Important in an Era of Change

"The reason productivity is important is simple," explains Maude Babington, Vice President of Consulting Services at PCA headquarters in Tampa. "We're trying to change what consultant pharmacists do, so we need to know how to measure their time commitments to various new tasks-as well as the old ones."

Babington names two reasons why beds per day or month is no longer an acceptable datum:

1. Acuity levels of patients differ considerably among practice settings and facilities. When a consultant goes into a home with a large number of new admits and discharges, more time will be required than in a home with longer lengths of stay or patients who are not as ill.
2. Consultant pharmacists must get away from retrospective chart reviews and into prospectively oriented disease management in which the pharmacist recommends drug therapy, laboratory tests, and nonpharmacologic treatments.

"We want our consultants to talk with physicians, to perform patient assessments, to work through disease management algorithms," Babington says. "Better care means happier residents and families. But it also produces lower costs for payers, better service for our clients, and, we hope, more business in the long run."

Babington continues, "I'm not sure our consultants can do all this plus 1,000 or 1,200 beds per month. We now expect them to check their e-mail several times each week and their voice mail at least daily. By giving our consultants the tools and the time to do these new things, we hope to prove that our consultants will be satisfied professionally, that our clients will be happy and will renew contracts, and that our business will grow."

Frontline Consultant Agrees

Van D. Weaver, geriatric pharmacy consultant with Neil Medical Group in North Carolina, could not agree more with the changing emphasis on the many things he does when visiting one of his seven nursing homes each month. As one of 16 consultant pharmacists in the group, he is responsible for about 900 beds. His target each "day"-a term used loosely to denote eight-hour time periods-is about 40 beds, and that's about five beds too many, he says.

"I actually work about 10 to12 hours per day," Weaver explains, "especially when I am on the road (which is 12 to 14 nights each month). With the addition of Minimum Data Sets to the previous drug regimen review activities, I really would prefer reviewing about 35 charts in an eight-hour period. By keeping the number of charts I review each day down, I am able to observe a medication pass in every facility every month, inspect the medication storage room frequently, and take an inventory of controlled substances at least twice per year. In addition, I provide one in-service program in each home quarterly."

The consultant pharmacists quantify the time they spend in each of these activities for corporate managers monthly, although Weaver says that they are not currently receiving feedback on their time management. Managers do have to balance out each consultant pharmacist's driving time, Weaver notes, which is important when the group's homes are spread across North Carolina and into West Virginia.

Making Productivity Personal

Both Saffel and Wendt emphasize personal sides to their management styles. Both spend time regularly working on the front lines with the pharmacists who report to them.

Saffel is very pleased with the labor pool she has to work with in the Atlanta area. "The skill level we find is excellent, and the reasonable cost of living translates into an optimal cost of doing business," she explains. "Further, I don't ask anyone to do anything that I am not willing to do myself-whether it's Sunday night start-ups or Friday night family meetings. This keeps people satisfied and their attitudes positive."

Wendt supervises about 35 consultant pharmacists from the Dallas office. "I work with each consultant pharmacist at least one or two times each year-actually going out to homes and seeing how they perform. My visit to the home gives us a good opportunity to spend time with senior managers of the facility, and I am able to assess how pharmacists relate to facility staff, how they spend their time, and what they really focus on. Then, with the data we collect, I am able to make the numbers and graphs much more meaningful-so that it's not just paper productivity. All these aspects are part and parcel of what the consultant is able to achieve in the time he or she devotes to the job."

Finding the True Solution

Wendt recalls the words of ASCP Past President Lynn Williams, who views consultant pharmacists as the solutions to their clients' problems: "We expect consultant pharmacists to be thinkers-to be problem-solvers. So it doesn't make any sense for management to come up with a solution and ram it down their throats. That's when they will rebel. If we just present them with the data, they'll find answers to their own problems just like they do every day in the homes we serve."

Compiling productivity data, presenting that data in meaningful ways, identifying and removing obstacles, and letting pharmacists find solutions to the remaining problems-that's a prescription for success.

Copyright © 1997 American Society of Consultant Pharmacists, Inc. All rights reserved.